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introduction medical training is a time when medical students undergo a great deal of mental and emotional distress the psychological status of medical students has become a source of concern as many previous studies have revealed higher levels of depression among medical students in comparison to the general population 1 2 3 4 5 6 a higher prevalence rate of depression and suicide among physicians compared to other professions is assumed to have its roots in medical schools and may reflect the effects of untreated depression 7 8 9 therefore medical students mental health is not only an issue for the individuals who are affected but also for the patients for whom they will provide care identifying the modifiable risk factors which affect medial students depression and the mental distress which they undergo is an important process in the promotion of medical students mental wellbeing medical students incorporate various health behavior changes in order to cope with the academic burden and stress of medical schools such as sleep deprivation an irregular diet and substance abuse such as the excessive consumption of alcohol and smoking 10 11 12 13 14 15 they also experience the degeneration of their social relationships due to the demanding schedules of medical training 1016 as the ability to maintain supportive relationships is known to have a positive effect when dealing with stress and alleviating depressive symptoms there is a possibility that this disintegration of social relationships may also be associated with depression among medical students 10 16 17 18 19 20 the economic status of an individual or household has frequently been reported to be a risk factor for depression among the general population in numerous previous studies 21 22 23 24 as medical schools impose a great economic burden on students and their families their economic status should be considered as a possible factor associated with their depression although the issue has great significance depression in medical students and its associated factors have not yet been thoroughly studied in korea the objective of our study was to estimate the prevalence of depression in medical students and evaluate whether perceived interpersonal social support healthrelated behaviors and socioeconomic factors were associated with depression in medical students materials and methods subjects and study design the subjects of this study were all of the 147 first and second year graduate students from a medical school in seoul and they were surveyed in september 2008 the subjects were all women and over the age of 20 the response rate was 816 with a total of 120 responses collected we excluded the responses of 31 subjects who had not answered at least one of the items on the interpersonal support evaluation list or the depression scale in order to assess whether those who were excluded were inherently different from those who were included in the analysis we carried out a separate analysis in which we found no significant differences in terms of factors of interest such as quality of sleep diet smoking alcohol consumption exercise and selfreported health status therefore 89 subjects were included in the final analyses survey and measures a survey questionnaire was constructed in order to evaluate the severity of depression the level of perceived interpersonal social support healthrelated behaviors and the socioeconomic status of the students their age body mass index sleep quality diet household income smoking alcohol consumption exercise and selfreported health status were surveyed in response to the survey question do you have meals regularly the participants were asked to indicate whether the answer was regular only skips breakfast or irregular in the analysis only skips breakfast and irregular were both considered under the heading irregular in response to the question how often do you exercise the answers that could be selected were never 12 times a week or more than 3 times a week in the analysis the answers were dichotomized by grouping 12 times a week and more than 3 times a week together under the heading yes in response to the question do you smoke the available answers were never stopped smoking or currently smoking in the analysis the answers were dichotomized as either yes or no in which the yes group contained both current and past smokers in response to the question how many times did you drink alcohol during the past month the respondents could answer as none fewer than 3 times or more than 4 times in the analysis the answers were dichotomized by grouping those who checked fewer than 3 times and more than 4 times into the same category group in response to the question what is the average income of your household the answers to choose from were less than 1000 thousand won more than 1000less than 2000 more than 2000less than 3000 more than 3000less than 5000 and more than 5000 the participants selfreported health status was evaluated by asking how would you evaluate your current health status the participants decided whether their own health status was good neither good nor poor or poor we used the interpersonal support evaluation list in order to estimate the degree of perceived social support among study subjects the isel is a 40item evaluation scale which measures the perceived levels of social support it comprises of four subscales reflecting separate support functions appraisal belonging tangibility and selfesteem all of the items were assessed using a fourpoint scale ranging from definitely false to definitely true although higher total scores indicate a more positive perception of the availability of social support a cutoff value for the optimum level of perceived social support has not been widely established we used the median value in order to compare the groups who perceived low and high levels of interpersonal support groups the internal consistency of the scale has been reported to be between a088 and a090 with a sixmonth testretest reliability level of 074 2526 the degree to which depressive symptoms were present was evaluated using the denter for epidemiology studies depression scale the cesd is a selfreport scale comprising 20 items which measures the major dimensions of depression 27 the frequency of each item is scored on a fourpoint scale ranging from 0 to 3 higher scores indicate more depressive responses and a score of 16 or greater is generally considered to be indicative of a depressive disorder it has been reported that with the frequently used cutoff of 16 the sensitivity of the scale for major depression is 100 and the level of specificity is 88 28 the reliability of the scale has been reported to be over a085 2829 statistical analysis the wilcoxon rank sum test and the kruskalwallis test were used to compare the cesd scores according to the factors of interest the chisquare test and fishers exact test were used in order to compare the rates of depression bivariate and multivariate logistic regressions were carried out in order to evaluate the association between various factors and depression all statistical analyses were conducted using sas version 91 a p value of 005 was considered to be statistically significant results the mean cesd score was 141±86 the isel scores ranged from 22 to 108 with a median of 910 perceived levels of interpersonal support quality of sleep diet and selfreported health status were shown to have significant association with the cesd scores the mean cesd score in the group who perceived low levels of interpersonal support was 184±78 which was higher than the mean score of the group who perceived higher levels of support students who had poor quality of sleep and an irregular diet also had significantly higher cesd scores the mean cesd score of those who had reported their health status to be poor was 193± 81 which was higher than those who had reported their status as neither good nor poor or good when the prevalence of depression was evaluated using a cutoff value of 16 33 of the students suffered from depression the prevalence of depression among students who perceived low levels of interpersonal support and had poor quality of sleep were significantly higher than those with higher level of support and good quality of sleep respectively the prevalence of depression were both 500 among students with an irregular diet and poor selfreported health status although this was not statistically significant in the bivariate logistic regression analyses students with low levels of perceived interpersonal support were more than five times more likely to suffer from depression than those with higher levels of support compared with those with a midrange household income those with a household income of more than 5000 thousand won were more likely to suffer from depression as with diet and the quality of sleep although these factors were not statistically significant their effect sizes were similar compared to those of the bivariate analysis discussion our study shows that the mean cesd score of medical students in a single medical school was 141±86 and that 371 of these students appeared depression our results also suggest that low levels of perceived interpersonal sup port increases the risk of depression by more than 10 times and that having a higher household income does not necessarily diminish the risk of depression we have also found some evidence that poor quality of sleep an irregular diet and a poor selfreported health status may be associated with depressive symptoms in medical students over the past few decades there have been an increasing number of studies that have evaluated depression and the mental health of medical students overall these studies have consistently suggested that levels of depression among medical students are higher than the general population and the students agematched peers 1 2 3 4 5 6 although it used a different scale to measure depression a study of university students in korea revealed that the prevalence of depression was higher among medical students compared to university students in other studies 30 the mean cesd score among medical students in our study was also higher than the mean score of korean women aged 18 or above in the general population 31 evidence from several longitudinal studies has suggested that upon entering medical school a students emotional status is not significantly different from that of the general population but levels of depression increases thereafter implying that a certain dimension of the medical education process and environment may exert a negative effect on students mental health 63233 the medical education process is very stressful in that the level of academic pressure and the workload is frequently overwhelming in many cases this causes medical students to either deliberately or reluctantly stop themselves from socializing developing personal relationships and enjoying extracurricular activities 10 in our study students with lower levels of interpersonal support were 10 times more likely to have depression this finding is supported by the results of numerous previous studies in which inadequate social activities resulted in a decrease in the psychological health of medical students 1016 these studies also showed that seeking social support was correlated with positive emotions in medical students 18 that stronger marital support predicted a lower rate of depression in medical students 19 and that students who thought that medical school interfered less with their social and personal lives were psychologically more stable 20 theoretically perceived levels of interpersonal social support are considered to reflect ones ability to cope with challenges to ones mental and physical health by buffering the pathogenic effects of stress 1734 although recent stressful life events are known to be associated with psychological distress and depression the level of correlation between the two factors is reported to be relatively low it has been speculated that this is due to social support which has the potential to mitigate the negative effects of stressful events in one historic study it was suggested that the number of stressful events and the degree of social support interact on depression 17 based on the evidence suggesting that stress levels among medical students are above normal this may imply that adequate social support would be more effective in reducing psychological stress and depression in medical students compared to the general population 1 in our study it was somewhat surprising to find out that subjects with a midrange of household income had a significantly lower risk of depression compared to those with higher household incomes similar results were found in a study in which the subjects with a midrange per capita household income had a lower likelihood of internalizing symptoms compared to the group with the highest incomes 21 although numerous studies with adolescents have indicated a positive relationship between low socioeconomic status and depressive symptoms 22 23 24 35 there have been studies in which a higher income level was associated with depression 21 or where the prevalence of depression was shown to be similar across household income levels 36 the results of this study add to the body of evidence that suggests that a lower socioeconomic status may not necessarily predict depression changes in healthrelated behaviors and lifestyle have been known to adversely affect the health of medical students 10 in line with our results many other studies have suggested that a decrease in the quality of sleep may occur as early as in the students first year in medical school and that this factor is associated with psychological distress among medical students 10 11 12 a longitudinal study observed that insomnia among medical school students is a risk factor of subsequent clinical depression 37 substance abuse including smoking and excessive alcohol consumption is a well known health issue among medical students although this was not evident in our study the results of other studies have suggested that the increase in smoking and alcohol consumption among medical students has detrimental effects on their mental health 13 14 15 however because these changes in healthrelated behaviors may also become manifest as a consequence or a component of depression further study is required in order to reach a conclusion on their causal relationships the psychological distress experienced by medical students is not only detrimental to their personal wellbeing but has been suggested to be associated with poor academic performance dropping out of school and suicide 16 it is also widely acknowledged that this psychological distress and poor healthrelated behaviors are not only apparent during medical school but are persistent throughout the students professional careers having a negative impact on the quality of patient care they provide 1 6 7 8 9 10 38 however despite the relatively high level of depression among medical students only a small number reportedly seek help or receive treatment 491039 this may be due to lack of access to mental health services for students in medical schools a lack of awareness of their mental health status or a reluctance to seek help due to the stigma attached to mental health counseling 34910 it is necessary that medical schools provide mental health services that students can access with confidentiality it is also recommended that medical schools incorporate an education program about depression and stress management courses as a part of the regular curriculum systematic measures put in place to encourage social support and extracurricular activities should also be undertaken it should be noted that due to the relatively small number of participants who were limited to first and second year students and who comprised a convenience sample from a single allfemale university the generalization of the study results is somewhat limited although it is generally acknowledged that the prevalence of depression is higher and the prevalence of substance abuse is lower in the female population 2313323540 there are studies which show no significant gender difference in terms of depression 69 further study with both genders should be carried out in order to gain stronger evidence although a selfevaluated questionnaire has the potential to cause measurement errors we had tried to minimize such errors or bias by treating the responses anonymously without collecting any information which would allow personal identification although our response rate was relatively high at 816 not being able to draw comparisons between the responders and the nonresponders remains as a limitation of our study another limitation is that the survey was carried at a single point out in time the beginning of a semester when the level of academic stress is reported to be relatively low resulting in the possibility that we may have underestimated the prevalence of depression 10 we were not able to analyze factors which are specific to medical students such as perceived stress levels and burnout along with other notable factors which are possibly associated with social support such as the availability of other family members at home and the type of housing 35 one other possible limitation is that the isel measures perceptions of the availability of support but not whether support was actually obtained however it has been previously reported that the perception of the availability of support is a more sensitive indicator than objective network measures because the buffering qualities of social support are said to be cognitively mediated 17 finally our cross sectional study design limits our ability to make statements about causal relationships several previous studies have indicated that degrees of psychological stress and depression change over the years in medical school while some studies have suggested that the psychological stress levels of medical students increase over time peaking in their graduation year 2039 other studies show that the deterioration of the psychological health of medical students starts as early as in their first year in medical school and peaks in their second year of medical school 6163235 the results of previous studies are inconclusive as to which time period during medical training is most stressful for the students and results may differ under different cultural and educational circumstances longitudinal studies measuring depression levels at different points during the years spent at medical school as well as within a semester would be the next step in further research despite these limitations this study identifies modifiable risk factors of depression such as lifestyle factors and interpersonal social support using the isel which is an objective measurement our results demonstrate that medical students have a relatively high level of depression and that efforts should be made to encourage the availability of social support in order to promote mental health in medical students conflict of interest

the objective of this study was to estimate the prevalence of depression in medical students and to evaluate whether interpersonal social support healthrelated behaviors and socioeconomic factors were associated with depression in medical studentsthe subjects in this study were 120 medical students in seoul korea who were surveyed in september 2008 the subjects were all women and over the age of 20 their age body mass index bmi quality of sleep diet household income smoking alcohol consumption exercise levels and selfreported health status were surveyed the degree of perceived social support was measured using the interpersonal support evaluation list isel depression was evaluated using the center for epidemiology studies depression scale cesd the mean cesd score was 141±86 and 371 of the participants appeared to suffer from depression low levels of perceived interpersonal support increased the risk of depression by more than 10 times and having higher household income did not necessarily decrease the risk of depression conclusion medical students have a relatively high level of depression efforts should be made to encourage social support in order to promote mental health in medical students

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sexual identity creating an antilgbtq sentiment that permeated military culture 910 as a result of this legislation more than 13000 lgtbq service members were discharged from the military for revealing their sexual identity at work 11 the dadt legislation was repealed in 2010 but recent research reveals that lgbtq service members remain hesitant to reveal their sexual identity in the workplace due to continued discrimination throughout military culture 12 13 14 in addition to these workplace culture challenges brought on by dadt lgbtq service members have historically faced many challenges as patients within military and civilian medicine 12 13 14 15 16 17 recent research has revealed that lgbtq service members have poorer mental behavioral and physical health than their heterosexual counterparts 13141819 these healthcare disparities may result from the stress of discrimination lack of support and systemic bias as well as lack of access to culturally competent healthcare providers within military medicine 131819 past research has found that 30 of lgbtq service members do not reveal their sexual identity to their healthcare provider due to fear of discrimination andor punishment 20 while these healthcare disparities for lgbtq service members and the impact of the discrimination they have faced have been studied no research has focused on military medicines workplace culture for lgbtq healthcare professionals who play an essential role in caring for the warfighter and ensuring force readiness 13 the purpose of this study thus was to 1 examine the experiences of activeduty lgbtq healthcare professionals at work 2 explore this populations perceptions of their workplace culture methods and materials our research team chose the phenomenological approach in qualitative inquiry to explore the lived experiences of lgbtq healthcare professionals and gather insight on their perceptions of military medical workplace culture as phenomenological qualitative researchers we aimed to describe and interpret our participants experiences from an insider perspective which we gained through indepth interviewing 21 the participants in our study were activeduty healthcare professionals who identified themselves as lgbtq seven of the participants identified as gay one identified as lesbian and two identified as bisexual all of the participants were members of the military medical community the participants were both enlisted and officers with ranks ranging from e406 to recruit for our study we used purposeful and convenience sampling 22 we emailed potential participants in our professional network providing them with information about the study and asking them to consider participating in our research or forwarding the information to others who may be interested ten service members responded via email and volunteered to participate in the study to collect our data we first developed an interview protocol consisting of ten openended questions we then conducted and recorded onehour virtual individual interviews with our volunteer participants using a semistructured approach to interviewing we also asked our participants to complete three emailed followup questions this study was approved by the institutional review board at the uniformed services university our research team then followed the steps outlined by giorgi et al for phenomenological data analysis first we transcribed the interviews using an automated transcription service 21 we then read the transcriptions multiple times in order to become familiar with them as a whole we coded each interview labeling each word or phrase that seemed to be representative of the participants perceptions we compiled these codes into a code book which listed each code and the corresponding direct quote we then organized these codes into major categories which described the participants structure of experience and formed the themes of our study 21 throughout this data analysis process we resolved any dissenting viewpoints through ongoing discussion until we came to a consensus 23 we took notes during each of our research team meetings to document this process 24 we took several steps to increase the credibility of our study our research team consisted of one activeduty military researcher and one phd civilian researcher with extensive experience in conducting qualitative research we used a team approach to analyze the data first analyzing the transcripts separately and then meeting to discuss them and come to a consensus on the emerging themes 23 we engaged in reflexivity by meeting on a weekly basis throughout the data collection and analysis processes to discuss and bracket our biases an essential process to maintain objectivity as qualitative researchers 2526 in addition after we transcribed the interviews we emailed the transcripts back to the participants so they could make any desired changes a process known as member checking 2728 results four themes emerged from our data analysis implicit bias explicit bias response to discrimination and recommendations for improving workplace culture theme 1 implicit bias and discrimination the participants first described implicit bias they experienced within the military medical community one participant for example described discrimination they observed in patient care there are a lot of assumptions made like for instance an individual who is single and wants to get on prep hiv preexposure prophylaxis they have to go to their primary care provider and in their record it has to denote that they engage in high risk sexual behaviors whether thats true or not…when you have a provider reviewing a chart they see that theres automatically going to be this judgment of like oh this person engages in homosexual behavior oh this person identifies with this sexual identity and with that can come a lot of implicit biases the participants also described a lack of social inclusion for lgbtq service members within the military medical community one recalled how there were some marines that in particular didnt like a fellow corpsman that was a gay male and the implication being that they were uncomfortable around him and youd challenge them why it was because of well you know another participant described their experience arriving at a new unit the people there knew that i was coming apparently warning everyone ahead of time that hey watch out theres this gay guy thats coming one of my roommates he was warned ahead of time about me as well he was hanging out with me and they were like hey you should watch out people are going to start thinking things about you because youre hanging out with this guy another participant reflected on their struggle to fit in socially with colleagues throughout their military career the experiences of lgbtq healthcare professionals within military medical culture i havent had a lot of outward negativity towards me but things that happened behind closed doors little things that were said about me that i heard or found out after the fact… i was like oh well that makes sense why it was so hard to make friends and why i didnt seem to fit in as well theme 2 explicit bias and discrimination the participants also discussed the explicit bias and verbal discrimination they faced at work one recalled how they constantly heard oh thats gay this is gay stuff like that is synonymous with gay is lesser it just makes you feel like you are not good you are lesser another echoed this struggle with hearing these discriminatory comments we were marching back to our barracks and the person calling cadence was saying random and just outlandish stuff like so and so is gay in the formation at that point my military bearing just broke i was like i cannot do this… i just had to stand up in that moment i said what you did is not right one participant recalled facing this type of verbal discrimination from military leadership as well during the time period that dadt was repealed i remember attending meetings during the repeal of dont ask dont tell a sergeant said something very homophobic and a marine captain who was leading it at the time agreed with him it went hey if we let in the faggots were letting aids into the marines the marine captain replied yes sergeant i agree with you unfortunately this is where things are headed with dont ask dont tell so we just all gotta kind of get on board with it another described how more recently their supervisor made critical comments regarding their behavior and affect ive received notes from people saying that you walk around and youre pretty happy… youre a bit bubbly then he said maybe i should give you more to do i replied by saying so is the expectation that im supposed to be miserable my supervisor replied no its just a little bit too out there finally the participants recalled examples of explicit biases from their graduate medical education programs one explained that there are faculty members who are not as affirming or not affirming at all…there was a faculty member who referred to transservice members as a project …definitely disheartened and discouraging theme 3 response to discrimination as a result of this explicit discrimination the participants described their hesitancy in revealing their sexual orientation at work one revealed that when i transfer to a new station i do an assessment first to see what the culture is like to see if they are accepting if they are tolerant and then from there i can start opening up more… so i kind of put on the heterosexual mask if you will when i first get to a place and then i can figure it out from there another service member echoed this same sentiment of hiding their true identity from their colleagues initially wanting to hide it really does have to do with more of a personal idea of masculinity… as well as how i will be perceived… because i dont want to be perceived by my sexual orientation…only by my merit and my work ethic another participant described their hesitancy in introducing their spouse to work colleagues i would be nervous sometimes at first bringing her to events just concerned that people might have a problem with it in order to navigate these workplace challenges the participants in our study described how they relied on the support of others who also identified as lgbtq both military and civilian i would stick with other gay people for the most part… i still have this unfortunate mindset of avoiding my heterosexual counterparts because i dont want to deal with their negative stigmas about me the participants explained how these networks they have formed replaced common support traditionally found in the military community in terms of the formal command programs like the spouse organizations… we really havent been part of that because weve found support elsewhere the participants also described how they relied on their spouses for support and resilience i think that we are all really good at relying on each other when we need things thatd probably be our biggest strength being able to be like im not in this alone theme 4 recommendations for improving workplace culture after reflecting on these challenges they have faced the participants recognized that progress has been made within military workplace culture regarding acceptance of lgbtq service members within the military community the military went from dont ask dont tell to there will be no negativity towards gay people its taken a very firm stance that even the majority of society in the united states hasnt really taken despite this legislative progress another participant described how military workplace culture is still catching up to this policy change the policy is changing but its slow and its not really transformative enough… i see the efforts i see the policy changes but theres just a need for more the participants made several recommendations for continued work in promoting equality affirmation and inclusion within military medical culture through education training and representative leadership outside of pride month it all kind of goes to the wayside…theres always going to be those senior mid or even the experiences of lgbtq healthcare professionals within military medical culture junior officers who have certain perceptions about individuals in the lgbtq community and that can create a very toxic command climate…so additional education programming and policies are needed the participants in our study noted that this training should be tailored specifically to meet the healthcare needs of the lgbtq community it would be great to have access to professionals such as in mental health and counseling that are trained to support the lgbtq community and their unique issues… theres definitely a training area to gain they also noted that healthcare professionals need to be educated about transgendered service members were told to accept trans service members because senior leadership says so but i just feel like theres a lot of confusion and a lot of not clearly knowing finally our participants emphasized the need for lgbtq representation in military medical leadership positions one summarized this sentiment i think as openly lgbtq individuals continue to move up in the ranks and continue to assume command just having that higher level visibility is only going to be positive for the lgbtq community discussion while past research has focused on the experiences of lgbtq service members as patients 121429 the results of our study revealed the experiences of lgbtq military health professionals within military medical culture and the ways in which they experience both implicit and explicit biases at work even post dadt these new findings mirror the results of past quantitative research that reveals the continuance of discrimination toward lgbtq service members throughout the military after the repeal of dadt 91214181930 this continued discrimination has resulted in high rates of separation from the military by the lgbtq population due to the challenges and discrimination they have faced 18 because retention of lgbtq healthcare professionals helps to ensure force readiness military medical leaderships are called to provide a respectful and equitable workplace environment where lgbtq healthcare professionals feel included and thrive in their daily work initial attempts at providing lgbtq culturally sensitive training for military healthcare personnel have proved promising 12 as suggested by the participants in our study more education and training is needed specifically focusing on increasing diversity and inclusion among military personnel including ways to increase the awareness and support of the lgbtq population impacted by the military healthcare system this training may result in the added benefit of an increase in healthcare professionals cultural sensitivity toward patients ultimately improving patient care and increasing force readiness 1213 military medicine might partner with professional organizations like the modern military association of america the nations largest organization of lgbtq service members spouses veterans their families and allies 31 this nonprofit organization recently created the rainbow shield program which educates community service providers and advocates through three certification levels the rainbow shield programs goal is to end negative experiences in service and advocacy settings based on sexual orientation and gender identity for service members veterans and their families 32 adopting an annual rainbow shieldlike program for the military healthcare system and military atlarge may assist in growing the understanding sensitivity and affirmation of the lgbtq population in the military in inclusive and equitable workplaces lgbtq healthcare providers are empowered to flourish 8 because healthcare leaders directly impact workplace culture 33 they are called to demonstrate open acceptance of the lgbtq population and become known allies and facilitators of lgbtq support networks throughout the military health system 29 military medical leadership is well positioned to model inclusivity not only within military medicine but throughout the entire military for example leaders might encourage lgbtq healthcare professionals to bring their spouses to workplace social events demonstrating the acceptance of diverse family structures leadership might likewise celebrate lgtbt pride throughout the year and actively participate in pride events in order to show support for lgbtq service members and their families 34 senior leaders might also facilitate staff education that focuses on health and workplace disparities and mentor junior leaders to create workplaces that model inclusive communication and support for all service members 34 due to the uncertainty of future landscapes of war force readiness is crucial 13 military medicine must be prepared to provide quality healthcare during the next conflict one step in ensuring this quality healthcare is creating a positive workplace culture within military medicine including creating safe spaces during deployments for lgbtq healthcare professionals the results of our study revealed key improvement areas within military medical workplace culture to focus on for improving force readiness future research future widescale quantitative research might survey a larger sample of participants within the lgbtq military medicine community in order to further explore their perceptions and experiences and explore other variables that may impact their experience additional qualitative research might explore the experiences of this population both before and after the repeal of dadt program evaluation of current lgbtq trainings within military medicine may reveal their strengths and areas for growth in effectively training military healthcare professionals to effectively support this population limitations none of the participants in our study identified himher as transgender further research is needed to determine the experiences of transgender healthcare professionals in the military and the unique support they may need in addition larger scale quantitative research within military medicine may reveal further insight into the experiences of lgbtq healthcare professionals within military medical workplace culture future research might also explore the differences in workplace culture within various professions and specialties conclusion the participants in our study described implicit and explicit discrimination they faced creating an inclusive workplace culture within military medicine for lgbtq healthcare professionals through training education and leadership representation can increase force readiness and patient outcomes data availability the data that support the findings of this study are available on request from the corresponding author all data are freely accessible conflict of interest statement none declared clinical trial registrationidentifier not applicable institutional review board this study was determined exempt by the institutional review board at the uniformed services university institutional animal care and use committee not applicable individual author contribution statement ra and rc designed this research collected and analyzed the data drafted the original manuscript and reviewed and edited the manuscript both authors read and approved the final manuscript institutional clearance institutional clearance approved

creating a positive workplace culture affects patient outcomes and force readiness an inclusive workplace culture is especially important for lesbian gay bisexual transgender and queer lgbtq military healthcare professionals who have historically faced discrimination within the united states military while research has examined lgbtq service members experiences in the military as a whole there is a gap in the professional literature regarding lgbtq healthcare workers experiences within military medicinethis qualitative phenomenological study explored the experiences of ten lgbtq military healthcare professionals we interviewed each participant for one hour our research team then coded each interview and came to a consensus on how to organize these codes into emerging themes we used reflexivity and member checking to increase the credibility of our resultsfour themes emerged from our data analysis 1 implicit bias 2 explicit bias 3 response to discrimination and 4 recommendations for improving workplace culture the participants described both the underlying and outright discrimination they faced at work they made recommendations for reducing this discrimination through education training and increased leadership representationour results revealed that lgbtq healthcare professionals continue to face discrimination in the workplace this discrimination must be addressed to create an inclusive workplace environment within military medicine which will enhance force readiness healthcare workplace culture or the way things are done through established attitudes values beliefs and practices which are exhibited within a work environment 1 directly impacts patient outcomes 23 positive workplace culture has consistently been correlated with lower patient mortality rates and increased patient satisfaction 3 ultimately when healthcare professionals feel less stressed they are more responsive to their patients and make less errors 4 5 6 healthcare professionals who trust their supervisors also feel more motivated and empowered to excel in their roles 7 supporting healthcare professionals who identify themselves as lesbian gay bisexual transgender or queer lgbtq is an essential aspect of positive workplace culture 8 however this population has historically faced discrimination within the military workplace in 1993 the dont ask dont tell dadt legislation prohibited lgbtq service members from openly revealing their

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introduction social positioning theory which is primarily an account of human community organisational structures has recently been brought to bear in framing orienting or otherwise informing investigations into the natures of a number of specific social items including money and the corporation 1 such endeavour however has yet to include any systematic consideration of the rather fundamental phenomena of human interactions and the sorts of human entities that engage in them here i do consider the bearing of social positioning theory on matters such as these according to the theory a human community possesses a number of interrelated components each formed by way of preexisting and unrelated entities becoming relationally organised through their occupying relevant positions the community components so formed thus possess relational properties that the original entities lack and so are irreducible to them with human persons amongst the entities organised through community positioning questions arise as to the properties they possess that enable them successfully to occupy such positions the nature of the relational human components that result and the sorts of human community interactions that occur given the relational nature of the participants addressing these questions it will be seen is not a straightforward matter for in most cases any given human person is an occupant of not just one but a number of positions simultaneously it follows that each person is also simultaneously associated with a similar number of different community components of varying communities thus a given person may through community positioning give rise to perhaps several of say a citizen of a country a particular type of gendered person a marriage partner a schoolteacher a local councillor a charity worker a nurse a member of a sports club of a political party of a dance or other social organisation of a religious group of an international academic association of various other international organisations and so on further and to add to the intricacies positions themselves are regularly transformed just as the set that any given person occupies frequently changes so that the set of components associated with the person is also everchanging if then we observe human community participants around us when out and about what sorts of beings or entities are we witnessing and do they qua social entities change at all when participant interactions occur seemingly each such entity prior to an interaction comprises numerous relational components at once but is any participant in an interaction a single community component say or a set of components simultaneously a timevarying mixture of these or something else perhaps the interacting entities differ according to place or context if so what determines the form of any particular interaction what furthermore must a human person be like to be able to support or underpin many different components at one and the same time seemingly as a way of life where furthermore is the human person either prior to or when human community interactions are occurring is it the case in fact that in the continuous flux of community goings on the human person effectively disappears altogether in short what are the natures of the human community position occupants and the community component participants they underpin how do participant interactions even occur given the seemingly complex if possibly fleeting natures of the entities involved entities that in virtue of multiple positioning appear either to be facing in no particular direction at all or to be looking out in all directions at once and where if anywhere is the human person in the resulting flux of community activity these are the sorts of questions i pursue here as it happens the nature of community or social interactions and their relation to associated entities is currently a topic of some debate in various branches of social theory specifically traditional accounts of such interactions have recently been called into question by social theorists seeking often under the head of new materialism to problematise anthropocentric orientations to theorising they do this specifically by way of encouraging a closer attention to the findings of certain nonsocial or natural sciences emphasising in doing so the nonpassive or active or agential nature of matter and process including interactions especially relevant here is a performative strand of this new materialism one that tends in fact to associate itself with quantum mechanics that stresses how human persons or agents and others engage with each other in a manner in which the interactions involved are a central productive feature specifically and in opposition to the traditional theorising of human agents or individuals as pregiven isolated atoms 476 t lawson acting on or interacting with purely passive material it is maintained that any social entities that figure in interactions do not exist as separate individuals prior to interactions but are rendered determinate only through different forms of interaction only in the context of certain types of interactions or so it may appear do the entities that are bus drivers or schoolteachers or nurses emerge this strand of social theorising then is especially focussed on the sorts of issues that are my concern here i find however that the social positioning conception in which powers and internal or constitutive social relations are core is if at first sight similar to the noted strand of contributions ultimately very different in its manner of accounting for the issues before us as such relevant versions of this new materialism provide a useful contrast or foil for purposes of briefly drawing out and indicating the significance of various features specific to the account derived by way of drawing on the insights of social positioning theory my basic aim though remains that of examining the bearing if any that social positioning theory has on the natures of the human entities involved in community life whether of the form of occupants of positions or the relational components formed out of them along with the manner in which community participants interact social positioning theory the theory in outline before i embark on the noted endeavour however i should elaborate a little on some of social positioning theorys central features and specifically those most relevant to the concerns of the current paper 2 to this point the theory has been concerned first and foremost with the nature of organising social structure and most especially community organising relations the conception sustained is one in which social relationality is found to be at the heart of all community life it is through preexisting elements becoming relationally organised that novel community components are formed if in the case of specifically human person components it is human persons that become relationally organised how or where or in what sort of manner generally speaking do these persons and social relations connect or come together according to the theory and how in doing so do they each stand vis a vis the other i start with their coming together as already briefly noted a key feature of community social structures according to the theory are sets of community positions that human persons and other kinds of entities can enter or be entered into these positions divide into person positions and nonperson or object positions with mostly human persons allocated to the former and nonperson objects or entities to the latter it is through entering or being entered into positions that human persons and other entities become relationally organised my focus here is person positions and in particular the manner in which through occupying such positions human persons become so organised and give rise to person components the mechanism is as follows community positions consist specifically of packages or sets of rights and obligations any specific right contained in a package constituting a specifically person position is matched to at least one obligation contained in a package also constituting a person position such matched rightobligation pairs are the community organising social relations when persons are allocated to or enter person positions they or their representatives have direct access to the rights and obligations that constitute the positions entered it is through human persons drawing on these rights and obligations that they and relational social structures make direct contact it is in this way that human persons become organised by community social relations the result when individual persons enter positions and so become relationally organised is that person components are formed that possess the relational rights and obligations in question these components usually also possess positional identities community organising social relations qua matched rightobligation pairs are clearly a form of powerover relation in that the exerciser of a right has powerover any party with a matched obligation these powers are deontic powers rights and obligations can be referred to as respectively positive and negative deontic powers they bear on the ways that any component so formed may or ought or ought not to act or engage that is these rights and obligations bear upon not the actions that can be undertaken that the component participants have the physical capacity to undertake but those actions that may be undertaken that the components are within the community permitted and required to undertake the positioning order is a normative one and deontic powers are clearly system and specifically community properties my concern here to repeat is the coming together of specifically human persons and community organising relations but i note in passing that the rights and obligations that constitute nonperson or object positions are subsets of those that constitute person positions it is the case once more that a relational community component is formed when an entity is allocated to any such position where such a component too has a positional identity typically however the constitutive rights and obligations in such scenarios are of course not accessed by position occupants but instead wielded by person components of the same community they bear specifically on the uses or ways of operating that are allowed for andor required of the object components formed by allocating entities to the object position and are thus included amongst the packages that constitute those person positions whose associated components have access to the object component in question 3 a further feature of the basic framework to outline here is that all community positions and so positional components are associated with functions indeed such components can be said to possess the associated positional functions functions too are relational being typically in effect built into the content of the rights and obligations that constitute the associated positions they serve to orient associated component actions or uses to being supportive of a communitys characteristic or usual ways of working or simply its survival functions too are both normative and system properties 4 i might also note finally that when a position to be occupied is itself novel occupancy of this position results in the constitution of a novel kind of component 5 such an occurrence entails some adjustment or extension of existing rights and obligations throughout the community ensuring that preexisting community components are where appropriate related to components associated with the new position position nesting the foregoing outline then indicates how according to social positioning theory human persons and social structures come together in a manner wherein human persons become relationally organised in the forming of community components a slight elaboration or extension of this basic framework relevant to the concerns of the current paper involves incorporating the notion of position nesting here i am concerned with position nesting in human communities in this context a position p n say is said to nest another position p n1 say andor be in turn itself nested in another position p n1 if p n1 consists of the collection of rights and obligations that constitutes p n supplemented by a few more and p n consists of the collection of rights and obligations that constitutes p n1 supplemented by a few more these few more rights and obligations of any nested position are determined typically to be coherent with those of all nesting positions my primary concern will be with nesting involving person positions 4 the identities or names of types of community components i might add are frequently indicative of their associated relational functions as for example with teacher student nurse carer bus driver identity card motorway pedestrian crossing dance hall bus stop shelter and so on 5 the kind in question is a positional kind meaning that the occupants of any particular community position are formed into instances of a kind associated with the position in question with each instance possessing the same package of rights and obligations and function in the terminology adopted for the current paper moreover it is reasonable to refer to the kind in question also as a component kind to observe that the terms positional kind and component kind are interchangeable in making this observation i should explicitly note and explain that i am using the term component for each of the instances of a positional kind whilst previously i have sometimes used it for the kind itself why the change of terminological strategy it is analytic to the term component that it relates to a whole it then follows as antonis ragkousis has reminded me that a component should be interpreted as a particular or as a kind according to whether the corresponding whole is a particular or a kind as my focus in the current paper is mostly on particular wholes or better totalities and specifically on particular human communities the term component is best also used for particulars that make it up clearly then positional kind and component kind in the context of the current paper express the same thing so each student at a given school x is a particular component being each an instance of the component kind student of school x erik van kesteren has provided additional a support for this terminological strategy through drawing my attention to the fact that the terms positioningposition and component both derive from the same latin verb ponere meaning to place or to put whereupon adding the prefix com results in componere meaning to place together with other things to form a whole the term positionem derives from the past participle stem of ponere and means amongst other things act of placing as well as position with the latter meaning from the 1540s specifically a place occupied by a person or thing the term component itself derives from the present participle of componere suggesting the continuous putting in place or being in place of some entity with other things to form a whole so where the term component is used in the context of social positioning it is found once more to be appropriate to use the term for an actual positioned person or thing an entity formed on putting something in place or into a position as part of the process of forming a whole or better totality rather than as a term for the type or kind of entity so formed the human person a simple case of person position nesting arises where in a community of ordinary member components a new or different position is constituted by way of adding a number of rights and obligations to those that constitute the position ordinary member an example is a seminar or a workshop where as well as the position of say seminar or workshop participant that of chairperson is also created with additional rights and obligations of a nature as to allow the positioned occupant to maintain an orderly discussion 6 communities can themselves be positioned to give rise to components of wider communities and cases of person position nesting occur where this happens thus if say a particular community is positioned to give rise to a university u and in the process a smaller community is positioned in the first community to give rise to a component of it in the form of a sociology department s then each person position in the smaller community s will be nested in a person position of the larger first community u at a basic level there will likely be a position of the larger community called something like member of the university u to which all individuals coming into the university have access if then in the smaller community s there is a position called say teaching member of the sociology department s it will be nested in the position of member of the university u by similar reasoning it can happen that a position called say member of the faculty board of sociology f becomes nested in the position teaching member of the sociology department s which in turn is nested in the position member of the university u 7 6 in some cases though the rights of the nested position may include those of not having to fulfil all the obligations of the immediate wider nesting position where this seems essential to fulfilling the obligations of the nested position thus the head of a university department may acquire a right to a reduced lecturing load 7 the reasoning behind such an example of person position nesting is a bit less straightforward than the brief description provided in the main text and warrants elaboration the situation as described involves a community c say that is positioned to give rise to a sociology department s in a wider community k say where k is itself positioned to give rise to university u because or where c is constructed with the intention of its being positioned to give rise to s its own positions will typically be named in terms of the nature of s thus c will likely include a position named something like teaching member of the sociology department as part of its organising structure and so amongst the components of c will be members of a kind called teaching member of the sociology department these components will possess rights and obligations within c as well as a function within c however because community c is positioned in community k all person positions in c will be nested in person positions in k and the most basic position in k which we can suppose all individuals coming to the university can occupy will typically be labelled something like member of u that is just as positions in c are named in terms of s on the expectation of the positioning of c to give rise to s so positions in k will be named in terms of u on the expectation or knowledge of k being positioned to give rise to university u so the position teaching member of the sociology department in c will be nested in the position member of u in k and we can say for short that the position teaching member of s is nested in the position member of u clearly the former position will consist in the package of rights and obligations that constitutes the position member of u plus a few more going further the community c may itself contain a position called the faculty board of sociology occupied by community c say here we might expect that positions in c are named and functionally oriented in terms of the fact that c is created to be positioned as the faculty board of sociology in c so we might expect a position like member of the sociology faculty board to exist in c thus in university u in the scenario as described the position member of the sociology faculty board is nested in the position teaching member of the sociology department which in turn is nested in the position member of university u and so on and when these nested positions have the same occupant the components that arise take the form of a member of university u that is a teaching member of the sociology department that is a member of the sociology faculty board t lawson such a set of nesting relations can be referred to as a chain notice that where a component is formed by way of a position p i say in the chain being occupied there will necessarily correspond a set of components associated with each of the positions in the chain that nests p i so if a component of the kind member of the faculty board of sociology is formed then bound up with it will be a teaching member of the sociology department a member of university u and so on here we might also talk of underpinning components in a chain being a member of the teaching staff of a sociology department underpins being a member of the departments faculty board etc 8 ultimately each such chain or set of underpinning person position components will bottom out in a human person i shall refer to such a chain and the associated components as being anchored in a human person 9 although any chain is anchored in one person only any given person p will typically anchor various chains simultaneously as well as occupy other positions that are not in any nesting chain 10 before though i seek to assess the implications if any of this outline of the theory regarding properties of the human person and associated person components i need to indicate albeit still at a general level something of how human persons and organising relations stand vis a vis the other if human persons generally speaking access organising social structures by way of entering community positions and if particular social structures are reproduced andor transformed through human person activities in total a feature i especially want to stress at this stage is that although human persons and social structure depend in this way on each other neither is reducible to the other each confronts the other possessed in this sense of a degree of relative autonomy let me then briefly consider the forms of irreducibility involved positional irreducibility the first form of irreducibility has been already noted it is simply that for each entity or element that comes to occupy a position the component constituted out of it is more than and in this sense is irreducible to the original 8 there is no presumption here that an underpinning component is necessarily formed before any others that it so underpins it may be thus in the noted university scenario a person may have to be positioned as a teaching member of the sociology department s before being and in order to be elected to member of the faculty board of sociology f but being appointed as a teaching member of the sociology department s may automatically entail being a member of university u even though the latter component underpins the former that is although the position university member may be wider than and nesting of that of teaching member of the sociology department it may also be that access to this nesting position is gained only by way of obtaining direct access to some nested position within it in the form of such a departmental position 9 it may be that grounded is a better metaphor to employ here given its connotations however grounded is a term used more generally or loosely in discussion whereas use of anchor can be more easily restricted to conveying only the meaning intended here the relevant form of anchor is something like a sea anchor that is not fixed but itself slowly moves and changes whilst yet facilitating a significant degree of stability for all that so depend on it 10 of course just as aspects of social structure will bottom out in a human person so all persons are always occupants of some or other position and so in practice relating to others so the human person will be shaped by being always a position occupant in other words the human person is not and was never a truly isolated entity and many if not most evolved features distinctive of the human person will be oriented to survival and thriving of each within a mode of existence involving not merely a dependency on but the actuality of always acting in relation to others so even the anchoring human person is inherently relational in at least this sense in short the human person will be shaped by having always been situated in social relations the human person element itself this form of irreducibility stems from the fact that when any totality is constituted it necessarily consists of something more than the base elements used in its formation that is the totality is more than the elements considered independently of the way they are organised if the bricks and blocks of wood and panes of glass used to make a particular house were randomly rearranged it is very unlikely that the outcome would be or possess the familiar properties of a house the specific organisation matters organising relations are a part of the house the house is more than the bare elements merely aggregated and this is the same as saying that each element used in constructing the house is relationally organised to give rise to a component that is irreducible to that element if say a pane of glass is organised to form a particular component of this house that is one of its windows this window of the house stands in a particular relation to the houses roof to an inside room and so on in a parallel fashion any component of a human community formed by way of an element occupying a position has relational properties not possessed by the element out of which it is formed this is so whether the immediate position occupant is already a relational component of some sort or an anchoring entity such as a person or indeed a material object such as a piece of gold president barak obama qua a component of the us system of government possessed relational powers that expresident barak obama does not and a communitys money formed by positioning a precious metal like gold or an item like bank debt has relational properties not possessed by the gold or the debt if this sort of irreducibility might be labelled downward irreducibility the second sort expresses the nonpossibility of reductions in the opposite upward direction here the point is that a position occupant cannot be reduced to in the sense now of determined by the social structure through which it is organised in the case of person components specifically a particular component associated with a given position need not conform to the rights and obligations constitutive of the position where doing so will usually be essential to its function being realised the point here is that the deontic powers and relations that are fundamental to the organisation of social reality constitute as earlier noted a normative not a deterministic order so those persons that gain access to packages of rights and obligations that constitute person positions are not bound always to comply with all or any particular subset and on occasion may not even be able to access or make use of those with which they are associated for a number of reasons then person components just like object components can on occasion at least be viewed as malfunctioning or being dysfunctional or in the case of human person components specifically purposefully obstructive of position functionality thus some occupants of person positions may simply be too young to be capable of accessing positional rights and obligations mary stewart was positioned monarch of scotland at the age of 6 days in addition various adult person occupants may temporarily or permanently be also unable to access or make use of at least some of the rights and obligations that constitute a position occupied directly or at least anchored for example person anchors may be temporarily indisposed as when one anchoring a professional footballer sustains an injury or one anchoring a teacher or student has a debilitating virus etc t lawson where in contrast a disability is permanent a representative may have to act on an occupants behalf just as representatives can do for nonperson occupants of person positions there will be cases too where anchoring persons either never were especially competent or perhaps have lost competency over time and the components they anchor are unable to fulfil their position functions despite these persons remaining anchors furthermore and certainly of no less significance there are of course cases where person anchors are so minded that the components they anchor qua components intentionally break their obligations they act in ways that by design diverge from any that could be interpreted as consistent with realising their functions of course there are also cases where such components not only fail to or actively resist and oppose keeping to positional obligations but seek even to transform or otherwise undermine them 12 i might note too that for any person p some associated components may act in line with their associated rights and obligations whilst others even within the same chain do not a citizen of c anchored in p may fulfil all the rights and obligations of being a citizen of c but underpin other component say that of being a partner of some sort where qua this partner he or she etc proves to be unreliable in the sense of continually breaking agreed obligations to the other partner so in sum a person p may be the basis or anchor of numerous components at one and the same time where each component will possess relational properties not possessed by p itself or indeed by any other component that underpins it just as all underpinning and anchoring entities are not reducible to the components they underpin or anchor and significantly the two forms of irreducibility identified have numerous layers an individual p will typically anchor very many positions and give rise to a large number of community components simultaneously but any such specific component y say will be irreducible to its anchor person p as well as to any other components formed out of p that in turn underpin y whilst any anchoring person p will always have powers of her or his etc own at the same time the functions possessed 11 significant here is the legal device of legal fiction whereby in law a position can have allocated to it an item x of a sort that was never intended to be so simply by way of the x being deemed in law to constitute an instance of a y where instances of y were indeed the initially intended position occupants an example is the manner in which in countries like the modern uk rights and obligations intended in their design only for human persons are allocated to corporations by way of allocating certain appropriately structured communities to the position legal person in creating instances of corporations 12 thus to illustrate some of these cases in turn many married couples live apart and yet remain married often thinking nothing of marriage obligations accepted by others a nations president may choose not to fulfil many presidential obligations and citizens of a country worried about climate change say may sit on motorways or in busy high streets fastening themselves to immovable objects or to each other in obvious contravention of highway obligations and so forth but others may graft away to get the rights and obligations that determine the positions they occupy transformed an obvious case is the history of campaigns to extend the right to vote to those positioned as womenso in many ways particular community components formed out of human persons can act inconsistently with the accepted functions of those components thereby contributing little to sustaining and often actively destabilising if usually temporarily the community of which they are components the function possessed by all components of any given kind and the actual functionings of particular components are different matters with it usually being possible for any particular component to operate in a manner that diverges significantly from any activity that is consistent with a realisation of its function the human person 483 by a component at any level y say may or may not be fully realised on specific occasions that y is active depending on the actions of components out of which y has been formed and ultimately on the capacities and orientations and decisions etc of the person p that anchors the specific chain involved so the human person never disappears within or into or departs from the social positioning process and nor is this person the sole determinant of all that happens organising community structures and human agency if always dependent each on the other each retain a degree of relative autonomy distinguishing the communitys human entities if all human community components then are ultimately anchored in some human persons it is however entities that are in part at least communityrelationally constituted that do the interacting indeed it is evident that any participant in an interaction at any point can only be that entity formed as a unity of a person and all the components that the person in question at that moment anchors it comprises a unity of many in one all located at the same place at any given point in time clearly this entity requires some elaboration i shall refer to any such entity as a human multicomponent or simply as a multicomponent where it is evident that the anchoring entity is a human person in so doing i stress that each multicomponent always involves only a single human person one located in a multitude of community relations and anchoring a cluster of different community components simultaneously this multicomponent is clearly a core subject matter for social theory being key to understanding the human activities on which the social world in large part turns before considering it further however i need to determine something about the nature of the human person that in significant part anchors the social edifice 14 for the capacities possessed by human persons will clearly bear on the nature of the multicomponents they anchor and so the way multicomponent interactions can and do occur my starting point here is that human persons are regularly observed to be highly successful in their accessing supporting and coping with community organising structures indeed it is unlikely that social structures would be reproduced or endure as they do if human persons did not continually draw upon them in a successful certainly in a competent and compliant manner here then i seek to determine something of the sorts of properties that human persons possess that enable them to be as successful as they are observed to be this success will indeed be largely down to the human person for although it is a feature of social positioning theory that social constitution depends solely on position occupancy that is that a community component is formed wherever and simply because a relevant position is occupied it is always the case that the nature and capacities of any position occupant bear fundamentally on whether and if so how successfully a component formed out of it is able to perform qua a component and in particular whether it is able to realise an associated component function so in sum there are two human entities to consider here namely the human multicomponent that engages in human interactions and the human person in which the multicomponent is always anchored focussing on those human person properties inclinations and capacities etc upon which the exercising and enactment of all component powers always ultimately depend both types of entity warrant understanding in themselves and both need to be so understood before i can address at all adequately the nature and possibilities of human community interactions i briefly consider each of these entities in turn starting with the human person the human person introductory observations the human person that successfully inhabits and indeed in large part anchors the social world is clearly a complex kind of being equally clearly this always in relations relationdependent but never relationally determined entity conforms neither to the fixed typically rationalistic atom of modern economics nor to the socialcultural dupe of much poststructuralist inspired social theorising what though is there to say about the nature of such an entity in particular what might be inferred in light of the way human persons are found to cope with social structures although it is hopefully already clear i stress that in pursuing this sort of question i am not supposing that properties of the human person can be simply and straightforwardly read off from insights into the nature of social structures i have emphasised that neither organising structure nor human agency can be reduced to the other nor i might stress am i supposing that all human beings are everywhere identical of course indeed far from it each is unique in so many ways this is an accepted given but there are commonalities as well and as just noted i am starting out from an a posteriori recognition or observation that whatever our differences most of us most of the time are able to and do regularly negotiate successfully the kinds of social structures that everywhere characterise human communities this suggests that at some level despite our many differences we nevertheless hold in common the sorts of capacities or dispositions or whatever that render such successful negotiating activities possible 15 my aim is simply to explore whether the natures of the activities in question along with relevant additional observations allow insights to be gleaned as to the sorts of capacities etc that human persons possess that are responsible for this successful activity 16 human persons no doubt possess common properties additional to any that are required to draw on or otherwise make use of relational organising structures with human persons always in fact being embodied beings there are powers or properties possessed that are enacted in an environment that is far wider than the social organisational some of which will be common to us all even so the sorts of features with which i am here particularly concerned will be essential to any adequate understanding of human persons as they have evolved to be any insights obtained as i say should provide an understanding of human persons and their capabilities even in conditions when they are not operating successfully as well as in any novel situations as may arise but especially in understanding how the community participants they anchor are able to interact i focus then on the socialstructural anchoring aspects of the human person especially however if as noted my starting point is a recognition that human community participants mostly participate successfully in all forms of human community life i need at this point to distinguish two aspects to this the first is a generalised competence or ability to so participate given the nature of community relational organisation the second is a widespread very significant degree of observance of or willingness to go along with structures in the face of many reasons for actual nonor minimal compliance both aspects warrant a degree of elaboration as well as explaining i consider each aspect in turn competent action within continuous social change and relational complexity in a world organised by the sorts of community relations elaborated in social positioning theory the observed continuous and largely successful navigation of these relational structures suggests first of all that human persons must come to possess an ability to grasp or apprehend these sorts of relations sufficiently to act competently within and through them in particular it must be the case that most human persons are able to grasp community components directly as components as the relational entities that they are rather than being limited to recognising only the items that occupy the corresponding positions i shall refer to this simply as the capacity of apprehension but as well as being able to grasp the relationality of human community life the human person must be able to do so in and generally to cope with conditions of continuous change and significant complexity for although organisational person that are thereby produced are not strictly entailed by social positioning theory account of community organising structure any more than any other form of explanatory account is strictly necessitated by observations on that which it explains moreover in addition to there being no logical necessity involved it is the case that it is not possible to move from a conception of organising structure to an account of relevant features of the human person so organised without bringing into play at least some additional empirical and other assessmentsthat of course even others committed to social positioning theory may not accept even so i am currently committed to the account that follows whilst it seems evident that any alternative social positioning theory informed account will be of a similar kind that is the conception advanced will i think be indicative enough of the sort of understanding that any positioning theory informed account will sustain of the sort of conception of central features of the nature of the human person the social positioning theory supports 486 t lawson social structure as theorised in social positioning theory can facilitate a significant degree of continuity and stability where it is adhered to everything that is social changes whilst there is usually a potentially bewildering array of relational structures having a potential bearing let me briefly elaborate social structure is continually being reproduced andor transformed through the sum total of human person actions both serving as the condition of these actions and constituting their product so along with everything else social community positions of the sort described in social positioning theory are always and everywhere in transformative process and complexity too is pervasive not least because each person occupies a multitude of positions simultaneously and so is always facing a wide range of component deontic powers or relations some of which may even be mutually conflicting in fact even where obligations are not inherently incompatible different personal concerns needs realised capabilities and personal considerations of whatever sort can still result in different obligations underpinning competing demands on resources and time the point here is that social structures do not somehow mechanically push or pull persons in relevant directions but must always be mediated to have an impact at all human persons though are found to be able not only continually to cope with the processual and complex nature of relational community life but also to form and pursue plans conditioned by the features and even evaluate uses made of community relations over time those entering positions as occupants are widely observed to make positional choices and commitments often on a longterm basis and somehow to be able successfully to maintain those commitments throughout this is especially so with positions bound up with specialist career paths or with the forming of traditional families in many communities and the like in effect occupants of such positions are able to formulate concern themselves with and actually achieve the goals of longterm projects involving significant investments of their time and effort in some instances for a lifetime often involving a significant amount of monitoring and adjustment of course for most occupants there are occasions to weigh up experiences and question whether particular position occupancies have proven over time to be worthwhile andor whether it is the moment for a change the point though is that despite the complex and everchanging conditions in which human persons find themselves most are found to be able not merely to cope with it all but both plan and evaluate competently and carry projects through even as all around is transformed these observations in total entail that at the very least each human person can individuate heror himself etc from others including the social context and over time specifically in order to make plans and act on them or make evaluative assessments of experiences the human person is seemingly able both to imagine heror himself etc as that same self in the future as well as to look back to heror himself at an earlier date and recognise heror himself as the same distinct and continuing person but in addition competent action in the face of the everchanging and competing if often conflicting demands conditions or concerns etc requires that each human person has the capacity not just to plan and evaluate but to undertake continuous acts of reflection juggling monitoring adapting thinking aloud and weighing up involving amongst other things an internal conversationsee the human person especially archer 2003 17 proceeding competently requires of participants that each is able to reflect on actions in context and weigh them in the light of possessed interests needs or concerns in short the observation that community participants by and large act competently in the sorts of conditions emphasised in social positioning theory reveals the human person to be an enduring individuating purposeful sort of being possessing various concerns and capabilities etc committed to relatively longterm projects and with the capacity to distinguish herself or himself etc and to consider that self and social contexts in relation to each other along with abilities to juggle assess and reassess whilst going along of course every human physical body is itself in a state of continuous transformation so if the noted sorts of capacities lie at the level of a human person it appears that they must take the form of a set of emergent properties of the person one consistent with the ongoing and continuous transformations of the physical body 18 so the capacities in question are presumably bound up instead with a dependent but emergent realm and specifically that of mental states or consciousness indeed the assessment that the human person possesses the sort of capacities described conforms to the view that each human person more fundamentally possesses something like a selfconsciousness or a first person viewing 19 capacity or perspective along with and closely bound up with intentionality the mental capacity to be about things properties and states of affairs intentionality is manifest in the making or holding of beliefs thoughts regrets preferences representations plans apprehensions and so on where such features are essential for purposeful action further to be able to imagine oneself in the future or to assess ones own past actions etc necessitates being able to form a concept of oneself it is to be able to think such thoughts as i was wrong to suppose that i could achieve x or i will seek to ensure that i will y in both cases the i that follows the word that is or presupposes a concept of oneself of the self that is of an embodied person on which the first i the subject is focused 20 and to determine whether to enter or 17 assessments of notions like an inner or internal conversation go back at least to plato archer herself in developing her conception of a specifically internal conversation provides critical comparisons with similar notions advanced by the american pragmatists most especially by charles sanders peirce but also by william james and george herbert mead the sort of notion in question also figures in a wider literature under a variety of headings including the inner dialogue inner speech inner discourse inner critic internal monologue and so on for additional accounts see for example vygotsky1962or hermans 1996 18 clearly emergent properties can persist through changes in the component parts of their bearer as with a house that continually provides shelter as extensions are undertaken or instances of various components are replaced or as an orchestra continues to make music even as it undergoes changes in personnel and perhaps even in structure so it seems not unreasonable to consider that an emergent property of the human body too might remain intact throughout changes to various lower level or component parts andor structures 19 the term viewing is of course a metaphor 20 if the ability to form a concept of the self is indeed essential to human personhood this does seem to require that we interpret human infants as persons only in potential even infants though appear to develop a sense of themselves manifest as they interact with physical objects around them 488 t lawson exit positions or how to act in either case requires as noted an ability to imagine oneself in relation to different contexts and these contexts in relation to oneself and so consider ones concerns or goals in relation to each and to determine which to pursue and how a first person perspective it is then something like a set of mental or inner properties or capacities such as these i suggest that must be possessed of human persons if they are to act competently within the sorts of relational structures defended in social positioning theory to systematise the set of capacities just outlined i use the label or expression first person perspective this is a term i borrow from lynne rudder baker who uses it to express collectively just the sorts of features identified above as a core component of her somewhat similar constitution view of the person and indeed although the conception i have outlined is rather different from most currently found in modern social science disciplines like economics 21 there is a more philosophically oriented literature that runs along similar lines bakers theory is an interesting and insightful example another of course is margaret archers account of the human person advanced as part of her morphogenic approach 22 21 in fact few attempts to theorise the human person or individual in a serious manner are to be found in the context of modern economics one significant exception is a collection of contributions by john davis the feature of daviss conception that seems closest to aspects of the account defended here is his notion of an individuals or an agents capability for or of its keeping a selfnarrative although this may reveal human persons to be distinct continuing individuals the grounding of it lies elsewhere i am suggesting and specifically in the possession of a first person perspective there is not space here for detailed comparison of the conception defended here and that provided by davis another exception is amartya sens capability approach and once more there is insufficient space available to make a comparison of the different accounts i note in passing however that sens core notion of capability at least as it figures in the wider literature inspired by sen refers not only to opportunities in the form of actions that persons may undertake but also things they can undertake because for example of their level of education or language proficiency level of wealth or skills etc and additionally because of their material circumstances combining all such enabling factors under the head of capabilities is likely to result in an account that is overly individualistic as well as misleading 22 margaret archer accepts the same sort of conception but focuses especially on that particular ability of human persons to mediate between varying social contexts in determining projects and courses of action based on their concerns this she systematises under the head of reflexivity what matters for persons is that they have an inner perspective which she lynne rudder baker named the first person perspective and i more demandingly term reflexivity because it entails i that is me in my social context considering what i should do there since different agents in much the same objective social situations engage in different courses of action we also have to introduce what matters to them such concerns give the traction that reflexivity works upon to design actions they hope will lead to the modus vivendi different agents seek in society the human person 489 in significant part too a similar sort of account was advanced 400 years ago by john locke 23 notably in these alternative accounts a first person perspective of the sort elaborated is taken to be not merely an essential feature of the human person specifically but the defining feature of person per se in other words person is considered to be a kind in itself where the human person is interpreted as merely one form 24 this is not an issue i can reasonably consider here where my focus is accounting for specifically human community participants and their activities of course it warrants emphasis that even if the essential and distinguishing feature of personhood per se is the first person perspective each person will always be an embodied being of some form here with the focus on specifically human personhood the relevant body is that of the human animal the biological human being 25 as a final point here if the possession of a first person perspective so understood accounts for continuity over time and the ability to individuate and so is regarded with reason as essential to being a person per se then possessing a particular and unique one is essential to being a particular person p say relational compliance despite unfavourable conditions competence of a sort required to apprehend social relational entities and to negotiate complex and everchanging organising structures is not yet sufficient though to account for the sorts of community activities of drawing on such structures everywhere observed for in a social system with a communitiesbased normative order such that participants can qua separate relatively autonomous entities decide whether or not to go along with some or all positional obligations the observation of almost total compliance everywhere and over time sufficient indeed for social structures to be continually reproduced must also be indicative of features of human persons it too is something to explain 23 in truth the basic insights stretch back at least to john lockes wellknown tract in his an essay concerning human understanding where locke describes a person as a thinking intelligent being that has reason and reflection and can consider itself as itself the same thinking thing in different times and places for locke then a person is a selfreflective entity the same selfreflective entity over time further locke supposes that the term person is a forensic one a property of agents that can plan and be happy and held to account but it is …consciousness which always accompanies thinking … that makes everyone to be what he calls self locke so it is consciousness that distinguishes selves and sameness of consciousness that underpins the diachronic identity of persons 24 for an argument supporting the idea that robots or ai could be persons so understood see margaret archer 2019b 25 a feature that is not clear to me in the accounts of others is whether in the case that person is taken to be a kind in itself other forms of possible persons are anticipated to be able to grasp and reflexively mediate specifically social that is human community relational structures and other concerns or even all contexts and concerns or merely at least some contexts and concerns or perhaps the ability to apprehend and reflexively mediate different contexts is not a necessary condition of the relevant notion of a first person perspective after all if this is the case then the ability to reflexively mediate particular specified contexts must be included separately as a capacity that is additional to the first person perspective when characterising the personstill as i say i cannot consider such matters here and i move on here for ease of presentation at least i do take the ability to reflexively mediate the various sorts of contexts as a feature of the first person perspective of the person per se and include the ability to apprehend and reflexively mediate specifically human social including community contexts and concerns as part of the first person perspective of the specifically human person t lawson according to the conception sponsored by social positioning theory of course human community participants qua participants are constitutively interrelated with each other in ways whereby the wellbeing of each human person that accepts to be a form of community participant depends inescapably on the actions and manner of acting of others specifically it depends on other related community participants being largely trustworthy in the sense of being compliant with their positional obligations whether as motorists on highways preparers of foods or medicines consultants retailers transporters of passengers teachers and so on getting involved and developing concerns is rendered feasible for each individual participant only where others can be relied upon to develop theirs in line with accepted rights and in particular obligations moreover given the allpervasive nature of community organising structures all persons know at some level that their actions qua particular community components always impinge on the wellbeing of other persons involved the fact of such dependency however does not in itself somehow guarantee that we all choose to act in line with our positional obligations or even proceed always or at all with others in mind structural obligations require reflexive mediation to impact and as stressed throughout it is always within our physical powers not to comply that we usually do comply remains something to be explained in fact most human persons qua participants can be observed typically not only to comply but in doing so to go out of their way to cooperate with and help others indeed compliance with social structures is mostly undertaken as a way of life as a matter more or less of course so much so that exceptions often take us aback most of the time most of us carry through obligations in a manner consistent with accepting a basic level of concern and respect for all others we mostly trust that others will adhere to their obligations and in turn we most of us most of the time show ourselves to be trustworthy in adhering to our own and we act in this fashion it is worth emphasising even in and despite the current pervasiveness of conditions in which survival let alone thinking of others is often difficult 26 and in the face of a prevailing ideology that emphasises selfcentredness and personal greed before all else 27 the fact 26 the state of the world system currently is such that economic political and other developments make it especially difficult to get by let alone always prioritise or even consider factors that bear upon the wellbeing of all under such conditions in fact it is easy to be drawn into blaming some specific other for our problems and for participants everywhere to become divided or led into supporting some individualistic forms of populism or other developments that offer simple apparent solutions to significant problems and such like that encourage us to forgo generalised otheroriented caring activities certainly there are many everyday reasons to deprioritise the sort of concern for others that compliance with obligations requires and reveals 27 much of the media perpetuates the impression that supporting individual greed is somehow a positive thing economic textbooks promote the idea especially here typically human persons are chacterised as in fact isolated selfcentred atoms motivated only by narrow notions of maximising subjective utility or by the narrow pursuit of profits or wealth usually at the expense of others where these activities are presented in a manner as to suggest that this is how matters ought to be simply put the general narrative widely perpetuated is that each community participant ought not to be constrained by or concerned with ideas of inclusiveness or oneness but accepting precisely to act as if each human actor is indeed but a relatively isolated merely selfserving atom with typically very narrowminded interests identifying this ideology as neoliberalism wrenn and waller capture it well in observing how it actively encourages and congratulates individuals for exercising selfinterested behaviour … being so relentlessly and evangelically individualist that the ideology leaves little room in the public sphere for care of others the human person that most persons in their daytoday activities nevertheless mostly act without hesitation in ways that are supportive considerate and so caring of others is in these circumstances especially quite remarkable and must i suggest be recognised as highly revealing of who we really are 28 and who it is that we really are i suggest is inherently moral beings fundamentally oriented to and concerned for the wellbeing of all we look out for others in most that we do and specifically we mostly stick to our positional obligations precisely because we are aware that and how others depend on us doing so and we are concerned for their welfare ultimately at some level we will the flourishing of all in our differences we have a disposition to do so in effect a disposition to care adhering to the organisational relations of human communities as a typical orientation is one manifestation of this this notion of care of course is a complex one expressing a muchstudied subjectmatter of various disciplines and literatures identified in many ways carrying various inflections which in some combination or other span features that seemingly bear upon and condition most that we do 29 it covers an orientation and inclination first simply willingly to enter into being including social being to be bothered to do so to treat it as mattering second to form or hold and pursue concerns and third of solicitude cooperation and ultimately of both willing and assisting the wellbeing of forms of being especially of other human persons these three inflections might if cautiously interpreted be summarised respectively as orientations or inclinations to care to care about and care for 30 28 in so arguing i am not suggesting of course that the sorts of positional rights and obligations that currently structure our interactions are in themselves always especially oriented to human wellbeing that as they stand they orient participants to actions that are consistent with a world of human flourishing indeed we are currently very far from such a scenario but we can only ever move on from here we have arrived where we are and we all are participants of numerous communities of some sort and reliant on each others compliance just to be able capably to go on in community life 29 currently following the contributions of carol gilligan especially the study of care of the sort covered here is a widespread prominent concern of feminist theorising in particular for an overview of much of the relatively recent literature especially the feminist contribution that also includes a survey of the coverage of care in the modern economics literature see davis and mcmaster sticking with economics specifically wrenn and waller in effect associate the disposition to care as elaborated here with veblens parental bent an instinct or orientation to solicitude for others that according to veblen in fact extends beyond children and other family members to the whole community this instinctive disposition has a large part in the sentimental concern entertained by nearly all persons for the life and comfort of the community at large and particularly for the communitys future welfare on veblens parental bent and care also see cumbers et al 30 the term care has a complex history and various inflections or interpretations two apparently competing understandings in particular have long prevailed thus in the latin literature of ancient rome the term care was employed to mean both worries and also orientations of solicitude and in particular of providing for or an attentive conscientiousness regarding or devotion to the wellbeing of one or more others it is this interpretation one that in the thinking of the stoics became the key to becoming truly human and for kierkegaard and heidegger the key to human authenticity that i am building on here primarily though both meanings are relevant an additional traditional inflection on the term care that i am also however incorporating is as a capacity or inclination to regard things not least forms of being as mattering as items of concern care includes a capacity to be concerned or to possess concerns as already noted without care of this sort human intentional doings or actions would not occur care is the impetus of human action it is because human beings care in this sense that in an openunpredictable and uncontrollable world cares qua worries and anxieties arise in an unpredictable world a human person must fashion her or his being and integrity through action and this would be impossible without the projects and concerns that rely on the disposition to care t lawson these orientations or inclinations are each essential for human life in communities given though my current focus on determining the conditions for generalised compliance with normative structures in situations where there is much that militates against doing so it is care as an inclination towards solicitude as a force driving towards achieving a situation of generalised human flourishing that i especially emphasise here in referring to care or caring as a disposition in this context i mean to express a capacity seemingly perpetually exercised that under the aspect in focus underpins a tendency continually in play to this end albeit one that because of countervailing contextual factors is not always fully actualised in specific activities no doubt the disposition is nonuniform across persons and countervailing or offsetting influences can sometimes be significant but the overwhelming evidence as i have elsewhere argued at length is of the tendency in question repeatedly showing through as ever prodding most of us along or pulling us back towards a path consistent with facilitating generalised flourishing it is the disposition underpinning this tendency that is always reorienting us towards acting in ways that support the wellbeing of all that as with the corresponding figure of goethes faust i am calling care clearly a more comprehensive account of these matters is warranted but this is not something i can pursue in 31 it is of course the case that in some instances participants are aware that they will be held formally accountable where obligations are broken and this in part may explain compliance especially in workplaces and situations of significant alienation and it is often argued that because or if and where certain individuals have weaker capacities for empathy etc emulation may play a role in explaining obligation compliance in some scenarios furthermore reciprocity may reinforce compliance though as i have argued elsewhere persons are more realistically understood as unconditional givers certainly i see no reason to suppose that an orientation of care can itself be treated as but a general obligation somehow derived from care already received from others though specific instances of care labour may take this form rather caring is basic to who we are and the reason that obligations are regularly met putting these various inflections together a disposition for care as interpreted here is or includes an orientation of concern for being in general and with the human person always situated in communities manifesting as components internally related to others with the wellbeing of each bound up with that of others a concern specifically for the wellbeing or flourishing of other beings especially human beings an orientation that can easily result in anxieties and worries 32 there are occasions it must be acknowledged where significant acts of harm are done even harmful acts though or at least those observed to be most common tend to reveal the commitment of most of us most of the time to the wellbeing of others for most forms of harm are in fact parasitic on more fundamental cooperative supporting and caring ways of acting requiring in fact that the caring activities are pervasive as basic human orientations thus dishonesty requires and exploits generalised truth and honesty untrustworthiness requires and exploits generalised trust etc even the shortcutting or avoiding of obligatory practices or norms can mostly make an advantageous difference only where and because the majority conform furthermore most acts of serious harm are arguably triggered in conditions of ignorance mistakes insecurity erroneous beliefs including most especially communitywide systempreserving ideologies misinformation fear alienation dehumanising forms of training or treatment or harm experienced and the like in contrast the acts of support sympathy cooperation and general caring that we more typically display not least as manifest in the observed largely continuous and widespread generous and wholehearted supportive and considerate compliance with the normative positional structures rest on a set of inclinations on the part of human persons that are themselves relatively continuous and selfstanding rather than sporadic contingent and dependent they are fundamental to us as we authentically are in being manifest in knowledge and critical awareness rather than error einstein was speaking for us all when he declared to readers of the new york times that only a life lived for others is a life worthwhile most significantly of all we return to acting consistently with such inclinations if and when any misleading or fearinducing etc conditions are transcended or disappear or relevant forms of critical awareness are obtained the human person the current paper here i am primarily emphasising that it is no small matter that human persons everywhere stick much of the time to their positional obligations and i am suggesting that this can be viewed as but one manifestation of the wider caring orientation or disposition that i believe is essential to who we really are its significance here is that it is a necessary condition for the reproduction of human community life and essential to the community anchoring activities of each human person so to take stock the human person i am suggesting is at base a human being with a human body the sort of animal that has biological capacities and needs and can interact with various other nonsocial beings that also possesses in an essential way something like both a first person perspective and a disposition to care it is these properties i am suggesting or others very much like them that account for the widely encountered features of human person competence and compliance in drawing on community organising structures requiring capacities of individuation and continuity in the face of transformative social processes along with orientations of considerateness support and cooperation in doing so these caring orientations being continually maintained in the face of and despite countervailing pressures and incentives to do otherwise the overall conception advanced i might note is clearly a form of emergent powers materialism with this conception to hand i now turn to consider the nature of the human multicomponent that is anchored in the human person before moving to examine the nature of community interactions in which this entity continually engages if general features of human structures allow that some inferences or insights be had concerning general properties of the human person an interesting issue is whether these insights allow us more clearly to understand in a general manner the nature of community activities in particular are we better able to understand multi participant interactions of a complex sort and especially those where the activities in evidence conform less straightforwardly or in intricate ways to generalised norms of practice but where the capacities and dispositions uncovered can be expected to remain in play the human social individual and human interactions the multicomponent the human multicomponent to recall is a unity of a human person and typically very many different relationally constituted components anchored in the terrain of the human person these components are properties of various communities so that the multicomponent is not then an entity that possesses its own components rather it is one that is formed as a composite of components reflecting the fact that the anchoring person is typically multiply positioned in ways that transcend specific community boundaries however with a particular human person being included as an essential part of any multicomponent being indeed its identifying feature and with each human person being an entity that can both individuate at any point in time and reidentify over time the same can now be reasonably said of any multicomponent i shall then also refer to a multicomponent as an individual and 494 t lawson specifically as a human social individual 33 in so doing i take it as understood that the multirelational entity so designated is very far from the isolated atom of some conceptions of individualism the term individual here does though signify that each such entity in question is a singular a concrete singularity in short the multicomponent is a historically constituted human social individual chacterised by an ensemble of social relations if then it is apparent that it is these human multicomponents that engage in community interactions a question that warrants being addressed is how particular interactions are determined or even possible for very clearly the nature of the human person elaborated is such that no matter how competent purposeful continuity facilitating or caring each may mostly be it will always be the case that not all components anchored in any one can be activated at the same time even if the conception elaborated leads us to expect that each multicomponent will most of the time seek to interact in line with its numerous component rights and obligations where relevant that is in line with its being an entity that is multiply internally related to other entities it is not clear a priori which package of rights and obligations will be drawn on at any moment moreover some component actions associated with a given person at least in specific contexts may even be mutually incompatible so for each multicomponent any interaction with others at a particular point in time will involve a subset of components and component powers being activated at most yet each such subset is anchored in the relevant human person so that features of the latter such as a first person perspective and a caring disposition will be in play whatever the scenario given the nature of each multicomponent the core factors determining those powers that are enacted in any particular interaction that determine the sorts of engagements that occur i suggest will be or certainly include the following the first is the nature and context of interactions and in particular the sorts of relations that constitute those parties that for whatever reason a multicomponent comes across or encounters the second is the anchoring person and in particular this persons inclinations to so engage or intentions regarding how precisely to do so within such interaction possibilities as emerge of course person actions occur at numerous levels of consciousness not just the discursive but even when carried out on a practical or tacit level it remains intentional the person always acts let me elaborate with an illustration 33 and the kind multicomponent might even be referred to as societys individual i do usually avoid employing the term society just because it is often used rather loosely in a fairly nondescript manner to capture features of any collection or grouping of communities andor individuals and often the whole of human social reality however that is just the situation i seek to express through employing the term here though a single component in an individuals make up is community specific and so internally related and oriented to others in the same community the individual qua multicomponent comprises many different community components simultaneously each being formed via processes of positioning where the set of communities implicated may be wide ranging spread across vastly different regions and peoples possessing different time durations degrees of stability significance and so on in short society is a term employed here for all the numerous social relations in which human persons are situated the human person community interactions suppose a multicomponent m is alone in a car in the uk driving to a café to get some breakfast at that moment m is manifest as a motorist on a uk highway and interacting with other multicomponents as a motorist so the community context of action and interaction is the highway or road system and the fact that m is positionally constituted as a motorist determines how m is related to any other multicomponent with which m does or may interact in that context m faces out to others as a particular motorist so person p that anchors m has activated the component of a motorist in virtue of entering in a car onto a road that is into the community context of action and interaction constituted by the uk highway system imagine further that a second multicomponent n say anchored in person q interacts with m on the highway perhaps they interact at a roundabout with n emerging from ms right on the roundabout as m arrives there in such a situation at least in the uk n has right of way matched to ms obligation to give way to all motorists such as n arriving from ms right clearly the individuals or multicomponents m and n are here facing and interacting with each other as community components of the form motorist of course not all motorists comply with their obligations or exercise their rights even on highway roundabouts the anchoring persons involved always have a say in how things turn out but still most driving most of the time is undertaken with sufficient care that accidents etc are rare as n approaches m from the latters right n trusts that m will wait patiently and not at the last minute try and squeeze recklessly in front suppose yet further that m and n both in due course arrive in turn at the same café to which m has been heading on arrival m chooses a seat outside in the sun and sits down with p thereby activating the cafécommunity component of customer 34 included amongst the components of which n is made up however is that of waiter or waitress at this café and q now activates this component so it is as customer and waiterwaitress respectively that m and n now face up to each other as n approaches m to take ms order that is m and n are once more interacting but here the community context of action and interaction is no longer the highway system but a cafécommunity and the manner in which m and n interact depends on the positional relationships connecting them as well as mutual care in the form of trust and trustworthiness of course any two interacting multicomponents m and n may manifest as two or more pairs of activated internally related community components at the same time where these pairs will typically be unrelated thus m and n may manifest as say partners and also as respectively a recently appointed lecturer and a phd student in the same university department perhaps even engaged in writing a research paper together where this is so and given the caring disposition of human participants we might expect that the interactions of m and n draw upon not all the rights and obligations associated with the components activated but only that subset of each matched pair of rights and obligations that are consistent with both sets of components in writing and researching together for example m qua lecturer is unlikely to pull rank put differently if we think of each pair of matched community components as determining a field of interaction possibilities then the actual interactions of m and n may have the appearance of interference patterns within the fields of matched component interaction possibilities as behaviours consistent with both sets of matched components are amplified whilst any contradictory behaviours are more or less avoided altogether it is hopefully clear then that and how contexts of interaction can bear significantly on the manner or form in which interacting multicomponents manifest at any point it is also evident that the manifestations themselves in turn bear on the patterns of interaction that normally follow for this reason indeed it may be thought warranted or at least convenient that the manifestation of a multicomponent at any point be identified as a character in itself if or where so we might refer to it as a prosopon 36 this term derives from the proposition pro which means towards and the noun ops which means appearance although it is a term encountered in greek theology and is often translated as person face or mask its original meaning or that possessed since at least homeric times is a selfmanifestation of the individual this would be its intended meaning here 37 but whatever terminology is adopted it is evident though i stress it anyway that the multicomponents that engage in interactions already exist prior to the interactions and continue to do so throughout so too do the human persons that anchor them as do any deontic powers that become exercised or enacted during the processes as well as the human person capacities and dispositions that are activated or enacted in the process of course both the human agent and the various levels of social structure are in continual transformative process but the entities involved are themselves at all times existent and in no way less determinate than the interactions that result the account of the nature of human actions and interactions that emerges then along with a conception of the entities and forms involved are if complex nevertheless quite coherent and intelligible even so i suspect that relevant aspects of the foregoing elaboration are easily misunderstood or at least and just as importantly the significance of various aspects of the account may not be apparent this is especially likely of the features emphasised in the preceding paragraph let me then consider very briefly a conception that is at odds with that paragraph so that it is apparent that the emphases made in it are warranted and significant interactionist social theorising clearly the human social individual of the sort that is entailed by or fits with social positioning theory is rather different to the isolated atom of much social theorising the human social individual of social positioning theory is relational rather than isolated and in process in a manner that involves being continually shaped by contexts rather than fixed and determined independently of any context even so and as just emphasised the human social individual of social positioning theory has been found to be not determined by or reducible to the social structure interactions with others a degree of autonomy remains this contrasts with other currently prominent accounts that in similarly rejecting atomistic individualist conceptions of the sort earlier noted do tend to deprive the person of any autonomy in particular there are contributions that in emphasising the productive contribution of interactions specifically go as far as to deny the possibility that any entities involved could preexist their interactions or at least to deny them any determinacy that is instead of assuming that pregiven individuals wholly determine the nature of their interactions it is proposed instead that the latter effectively wholly determine the former as noted at the outset a number of these are influenced by a reading of quantum mechanics specifically here i briefly consider karen barads agential realist account of this nature a contribution that has been especially influential on feminist theorising as it happens much at least of barads assessment is easily interpreted as presupposing a perspective similar to that of social positioning theory and so not something with which i would want to take issue however barad herself would seemingly strongly resist any such suggested association or comparison certainly many of her statements taken at face value do amount to a very different interactionist conceptionthough barad prefers the term intraactionistand indeed are regularly so interpreted by sympathisers and critics alike that is they are easily and regularly understood as denying that any kind of individual or entity can exist or anyway be determinate prior to any human interaction i cannot go into the issues involved at length but content myself with briefly noting some indicative statements or assessments a core term for barad is as just noted intraaction barad defines this term by way of contrasting it with the notion of interaction she thus writes for example that … in contrast to the usual notion of interaction which assumes that there are separate individual agencies that precede their interaction the notion of intraaction recognizes that distinct agencies do not precede but rather emerge through their intraaction clearly it is easy as i say to suppose that barad and i are getting at the same sorts of phenomena using different terminologies and so perhaps her use of terms like t lawson emerge might be interpreted as meaning something like are activated 38 but this is certainly not how barad is usually interpreted and passages such as the following suggest that barad herself does indeed intend to suggest that interactions cause entities to come into existence thus barad insists that individuals do not preexist as such but rather materialize in intraaction that is intraaction goes to the question of the making of differences of individuals rather than assuming their independent or prior existence or subjects and objects do not preexist as such but are constituted through within and as part of particular practices in keeping with the suggested interpretation furthermore barad insists that agency is not and indeed cannot be possessed but rather is entirely a doing a phenomenon of intraaction crucially agency is a matter of intraacting it is an enactment not something that someone or something has it cannot be designated as an attribute of subjects or objects it is not an attribute whatsoever agency is doing or being in its intraactivity in all this barad presenting herself as drawing explicitly on niels bohr is seemingly minded primarily to treat all agents including those of the social entities as on par with a particular standard or copenhagen interpretation of quantum entities or objects associated with bohr for according to this theory as physicistphilosopher carlo rovelli puts it the discovery of quantum mechanics is the discovery that the properties of any entity are nothing other than the way in which that entity influences others it exists only through its interactions suggesting that quantum theory applies at all levels including the cultural rovelli elaborates suggesting that according to the theory individual objects are the way they interact the properties of objects exist only in the moment of their interactions and everything consists solely in the way that it affects something else indeed rovelli is clear in the view that the best description of reality we have found is in terms of events that weave a web of interactions entities are nothing other than ephemeral nodes in this web their properties are not determined until the moment of these interactions … and so on this does all seem implausible of course at least as a conception of social entities if conceptualising human social individuals as a product of their interactions is assessed as being 38 certainly the accounts sound similar in my own use of the term interaction i recognise that wherever an interaction involves human persons it will always involve two or more related components of a community say an employer and employee or teacher or student parent and child etc these components are relationally constituted they do not exist in the absence of the specific relations involved even so interactions that ensue do not create these components but merely stimulate their activation while a child is at school the parent still exists qua a parent even if located now in a workplace and enacting employee powers including obligations interaction in the household may achieve the activation of parental deontic powers but the person the parent and the powers along with the child and her or his rights etc all exist prior to any such encounter as i say this may be the sort of account that barad too intends though prima facie at least it seems very different the human person essential to conforming to a quantum conception then where this assessment is accepted along with the goal of seeking quantum social theories it serves as a constraint on the sort of conceptions of the social agent that can be entertained in contrast social positioning theory is not so constrained it rejects not only the traditional notion that social human individuals or agents wholly determine their interactions but also the equally implausible idea that individual agents are somehow produced by or at least rendered determinate by these interactions 39 social positioning theory rather is derived with the aim of producing a conception of social reality that is explanatorily powerful or empirically adequate with respect to the phenomena of the social domain certainly it seems more plausible and explanatorily sound than the new materialist essentially poststructuralist alternative considered 40 i do acknowledge that there are various insights that are broached in the noted statements by barad and others but i can discern none that are not shared with social positioning theory or relevant specific conceptions that it sponsors thus all such accounts stress that human persons never do exist in isolation but are always beingsinrelations and that all entities and structures involved in interactions are affected by reproduced andor transformed through them etc it is just that for the social positioning theory and associated conceptions various entities certainly in the social realm are coresponsible for daily interactions even where and where so as they are reproduced andor transformed through them in short although the relational powers of the multicomponent individual of social positioning theory may be activated and enacted through the onset of specific interactions the relations the components and their powers the position occupants and their capacities and dispositions along with the social individuals themselves all exist prior to any such interactions a thoroughgoing depth realism is at all stages preserved final comments and conclusion social positioning theory being of the nature of a philosophical ontology is most clearly of use to substantive analysis a phenomenon is a specific intraaction of an object and the measuring agencies the object and the measuring agencies emerge from rather than precede the intraaction that produces them of course use of the term interaction does not necessitate a commitment to individualism interacting agents or entities can even be internally constituted the relations can be explicit or clear from context and in fact whilst the term inter means between different things the term intra usually means within a given thing so that use of either term seemingly presupposes one or more already existing entities 40 if however i am here misunderstanding barad and we are after all proposing similar sorts of conceptions then i hope that the social positioning theory account of the human social individual can still serve as a contribution to the general discussion in particular i hope it can be an aid to clarification indicating in a different manner the sort of entity that participates in human community interactions from the social positioning theory perspective though it is very clearly an error to suppose that societys individuals or entities cannot preexist any interactions the situation rather is that such interactions bear on the form in which the preexisting human social individuals manifest 500 t lawson modern academic economics when employed as a ground clearing device not least as a means for resolving social theorys most enduring general puzzles and problems 41 the continual treating of the human person in substantive theorising as some version of an isolated atom is a case in point 42 it is often feasible though for a philosophical ontology to be utilised further in underpinning or sponsoring projects in scientific ontology that is those concerned with the natures of specific items in this regard a philosophical ontology may at least provide a conception or framework to which scientificontological assessments or theories can conform or otherwise relate or be oriented there is however no unique way of going about developing such scientificontological assessments or theories and it will always be the case that additional empirical and other claims are involved that are not merely fallible and contestable but perhaps contested even by those that currently commit to the philosophical ontology so employed and the same applies to any inferences drawn the attempt here to theorise the human entity employing social positioning theory constitutes in effect such an endeavour in social scientific ontology and its results may indeed be so contested 43 for not only are traditional accounts of the nature of the human individual rejected here as quite unsustainable with clearly highly contestable assessments made in developing an alternative but also it has been found necessary to identify various different human characters or forms as a result the whole scenario of community interactions is rendered somewhat more complex as well as context dependent so there is certainly scope for disagreement 41 for such puzzles and problems are frequently found to result from implicit and mostly unexamined ontological commitments or preconceptions that necessarily accompany all substantive theorising and use of methods of analysis but do so mostly unrecognised when these preconceptions are rendered explicit they are usually easily shown to be untenable revealing the associated substantive claims or choice of methods through which they enter the analysis to be equally unsound 42 the context of the current paper indeed includes as noted throughout a recognition that modern substantive theorising is enduringly beset with problems of sustaining realistic accounts of the human individual its basic causal entity the ontology of human persons or agents as isolated atoms regularly creeps in almost unnoticed due in large part to an emphasis on mathematical modelling that carries a commitment to this ontology however implicit this ontology in turn necessitates substantive assumptions that are consistent with it which usually means theorists treating the human person or agent of analysis as a selfcentred endlessly greedy often allknowing perfect calculator of thoughttobe optimal situations within the fixed parameters of some closed scenario and so onit is then in large part simply a failure to pursue ontology in a conscious and explicit manner that allows such absurd constructions to persist this is perhaps especially well illustrated in the current context by the contributions of amartya sen there is no doubt that sens account of the human individual systematised as his capability approach is enormously insightful and deservedly influential however despite this contribution so clearly comprising a systematic social and ethical ontological analysis sen confuses matters by both formally distancing himself from the very idea of ontology being a useful form of study for the social realm and ethics and also in doing so actually associating his overall contribution with support for mathematical modelling methods of others in this sen seems not to appreciate that the methods supported necessitate the noted untenable ontological presuppositions that are not only absurd but significantly at odds with those of his own capability theorising on this see martins lawson and ragkousis 43 it also follows of course that if the conception of the human person or of the human social individual etc defended here is shown to be inadequate in some way this per se does not undermine the social positioning theory drawn upon in developing it the human person 501 even where social positioning theory is accepted even so i do suspect that any formulation based on its acceptance will run along lines that in general terms at least are not too dissimilar to the conception defended here in any case i am led to the view that it is warranted that we recognise not only the human person but also the multicomponent a human social individual comprised of a unity of all the relational community components anchored by any given human person along with this anchoring person the complexity of the typical multicomponent is such that not all components of which it is comprised can be activated simultaneously and the specific components that are in fact activated at any point depend largely on the sorts of contexts and the others with which the multicomponent comes to interact it is this specific set activated at any point that along with its anchoring human person that will be determining of the patterns of interactions as occur it is a feature of the conception defended however that whatever the component activations that occur in community interactions they presuppose the prior and continuing existence of the associated multicomponents under all their relational aspects anchored in equally preexistent human persons so in contrast to various currently prominent competing accounts of the human social individual the conception sustained posits a relativisation not of being or existence but rather of activations of particular states of being clearly the account of the multicomponent and of human community interactions defended may be complex in its details but i repeat however there is nothing especially strange counterintuitive or unintelligible about it as to the human person specifically i have argued that in place of the isolated seemingly positionless selfcentred usually greedy allknowing merely calculating typically optimising and mostly short sighted and narrowminded atom of traditional theorising a relationally positioned relationally competent relationand processattuned and yet relatively autonomous selfconceptualising reflexive and project forming as well as essentially otheroriented caring concerned giving cooperative and supportive though fallible and indeed often misguided and misled human entity can with advantage move centre stage the sorts of features noted have been systematised by way of developing a conception of the human person as possessing a first person perspective and a disposition to care i might add finally that if the account defended is at all correct it also bears clear consequences relating to projects and strategies for social change especially those of an emancipatory nature for if social reality is as presented projects of meaningful change will certainly include transforming or replacing the positional relations that provide and set limits to the opportunities we all face and so with removing obstacles to doing so so specifically emancipatory projects will include removing those particular obstacles that impede our seeking to ensure both that nonoppressive and nondiscriminatory generally wellbeing facilitating opportunities everywhere prevail and also where it is meaningful that all positions not least those of significant opportunity are accessible to everyone in other words a fundamental focus will be on the sorts of social transformations that 502 t lawson

an account of the nature of human community organising structures has been systemised as social positioning theory here i explore the sorts of human entities that are able successfully to draw on and make use of community structures of the form portrayed in the theory focussing especially on the sorts of human community interactions that are facilitated

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introduction diabetes is a chronic illness 1 and affects over six percent of the worlds population 2 similar to other chronic illnesses living with diabetes is a daily battle of selfcare and decision making 34 patient education and psychosocial support anxiety stress management 5 and better treatment adherence 6 diabetes patients have to follow a strict regimen in terms of diet and exercise the regimens often bring communication breakdown between patients vs caregivers often referred to as diabetes police 7 or significant others overtly monitoring food consumption of diabetes patients in such situations many patients switch to social media for social support 8 social media enables them to share new forms of narratives that are quick symbolic and ad hoc 9 providing instant means for selfexpression and identity formation 10 in particular visual narratives such as photographs help them to express in forms meanings that are otherwise not easily conveyed through words such visual forms of selfexpression produce illness narratives that help patients with diabetes to make sense of life events such as career family marriage sex and intimacy among others sharing narratives of personal experiences through social media is found useful in improved selfmanagement behavior 11 illness narratives seem to have therapeutic effects for the writer and strongly influence the readers to understand the writers context 12 diaries blogs and other illness narrative expressions have also shown to produce therapeutic effects on social relationships and selfhelp 13 specifically this study examines the visual illness narratives of diabetes on the tumblr social media site the findings have implications for employing visual narratives to improve chronic illness care for diabetes patients studying visual illness narratives can also help healthcare providers researchers and caregivers to understand the challenges that patients experience and can have design implications for better disease treatment healthcare 2022 10 1748 2 of 14 visual research methodology visual research methods have a long history in qualitative health research for example kaley hatten and milligan 14 conducted a visual ethnographic study to explore how individuals with intellectual disabilities engaged in green care harvey and brooks 15 explored the role of stock images in forming perceptions of patients with dementia cheezum rosse niewolak and cobb 16 conducted a photovoice study to assess the determinants of health and wellness in detroits homeless community additionally researchers have used photovideography in data collection and in the analysis of daily computing environments 17 and visual methods to explore humancomputer interactions 18 including design projects and visual ethnography 19 other visual research methodologies include visual ethnography 20 ethnomethodology 21 documentary photography 22 photo elicitation 20 and photovoice 23 considering the abundant use of visuals on social media visual research methodologies are also experiencing a transition from traditional objectivist forms of data collection and analysis to more subjective ways of looking into culture and social life as evidenced by more recent work in sociology and anthropology using photographs illustrations and videos 2425 illness narratives studies of illness narratives describe two distinct languages of discourse around health the first is objective language which includes medical information provided by physicians and other health providers the second is subjective language which talks about the intimate nonverifiable experiences around having an illness frank 26 discussed the critical role of such subjective language in illness narratives as ill people learn by hearing themselves tell their stories absorbing others reactions and experiencing their stories being shared illness narrative is shaped by a mix of interactions a patient has with other patients similar to himself family and providers these could be inperson interactions and interactions taking place in mediated environments such as websites or mass media researchers found that giving the opportunity to tell personal stories about their illness helps the participants to actively participate in their health improvement process 27 in addition by hearing stories from similar others they do not feel alone in experiencing the illness 26 the conventional method to achieve this is through maintaining patient diaries for instance patients have produced narratives of their illness experiences and hospital stays in the icu 28 healthcare providers have also recognized the importance of illness narratives they use illness narratives to learn about the patients life after disease 29 intensivecare nurses use diaries to record their experience which is often coauthored by other healthcare providers and even patients family members 30 for example a study examined the effects of digital photosharing on the social connectedness of patients with spinal cord injury and elderly living in a nursing home 31 the results showed that the sharing of photos served as food for the talk and improved the bonding with family members visual narratives with the presence of new media and communication technologies people have found more elaborate ways to express their daily life stories among these people use photographs to communicate through signs and symbols about concepts that are generally hard to convey in words 27 the method has the potential to reveal hidden meanings as well as new opportunities to understand and improve disease management patients lived experiences might not always be possible to verbally describe narratives presented visually provide a unique window into the subjective experiences of the narrator 27 for instance a picture of swollen feet and the persons painful gesture provides a window to see beyond physical symptoms and feel the emotional side of the patients struggle with the illness such visuals also show subtle details that are often not shared during medical visits visual narratives take several forms including but not limited to photography 32 and graffiti 33 the ubiquity of visual social media sites has led to a significant increase in the visual sharing of illness narratives thereby increasing social interactions around it this has been studied in many health contexts such as hiv aids 23 chemotherapy 19 and posthospital recovery 32 visual narratives have also been used to study embodiment 34 body image and how it shapes the personalsocial identity 35 to that extent images provide a unique avenue to express and understand illness narratives with more richness tumblr a place for sharing visual narratives tumblr is a visual social media site that is popular among internet users with its fast signup procedure and microtext images and photographs sharing abilities the website hosts over 518 million blogs 36 it publishes over 12 million blog posts daily and has over 327 million unique visitors around the globe the posts are categorized as photo video audio text link chat and answer several of these posts are reblogs with roughly 10 original posts 37 in terms of posts sentiment image posts express more intense emotions and positive valence compared with textonly posts 38 healthcare 2022 10 x for peer review 3 of 14 narrator 27 for instance a picture of swollen feet and the persons painful gesture provides a window to see beyond physical symptoms and feel the emotional side of the patients struggle with the illness such visuals also show subtle details that are often not shared during medical visits visual narratives take several forms including but not limited to photography 32 and graffiti 33 the ubiquity of visual social media sites has led to a significant increase in the visual sharing of illness narratives thereby increasing social interactions around it this has been studied in many health contexts such as hiv aids 23 chemotherapy 19 and posthospital recovery 32 visual narratives have also been used to study embodiment 34 body image and how it shapes the personalsocial identity 35 to that extent images provide a unique avenue to express and understand illness narratives with more richness tumblr a place for sharing visual narratives tumblr is a visual social media site that is popular among internet users with its fast signup procedure and microtext images and photographs sharing abilities the website hosts over 518 million blogs 36 it publishes over 12 million blog posts daily and has over 327 million unique visitors around the globe the posts are categorized as photo video audio text link chat and answer several of these posts are reblogs with roughly 10 original posts 37 in terms of posts sentiment image posts express more intense emotions and positive valence compared with textonly posts 38 even though tumblr appears similar to other visual social media sites some differences still exist for example pinterest lets users curate images flickr lets people view and like others photos but not share or reblog on flickr tagging behavior occurs significantly among friends accordingly popular photos do not spread widely and quickly on the network over 50 of information exchange is between online friends but with a significant delay at each connection 39 however tumblr makes possible the quick dissemination of information through the reblogging feature similar to twitter several researchers have used tumblr blogs to study health topics these include visual representation of anorexia and found blogs containing emotionally intense and triggering images 40 tumblr has also been used to examine visuals of domestic violence through a feminist participatory action approach 41 most research on illness narrative is based on textual data generated from written diaries surveys focus discussion groups and indepth interviews however qualitative data exist in other nontextual forms such as signs symbols nonverbal gestures paintings and other visual artifacts visual communication offers significant opportunities to explore lived experience and the subjectivity of patients illness experience 27 this is particularly relevant for patients with diabetes that puts them in awkward social situations such as having to inject a needle before a dinner date and having to worry about telling a blind date that one has a disease that is not curable as patients tell their story they untangle their illness experience and begin to accommodate to life as the person they have become based on this discussion this article presents a qualitative analysis of diabetesrelated images on tumblr and explores how patients use tumblr in the context of expressing their illness our study informs how visual social media sites can be developed to effectively enhance patients illness experiences and help stakeholders such as providers and caregivers to better understand the patients perspective leading to improved patient care even though tumblr appears similar to other visual social media sites some differences still exist for example pinterest lets users curate images flickr lets people view and like others photos but not share or reblog on flickr tagging behavior occurs significantly among friends accordingly popular photos do not spread widely and quickly on the network over 50 of information exchange is between online friends but with a significant delay at each connection 39 however tumblr makes possible the quick dissemination of information through the reblogging feature similar to twitter several researchers have used tumblr blogs to study health topics these include visual representation of anorexia and found blogs containing emotionally intense and triggering images 40 tumblr has also been used to examine visuals of domestic violence through a feminist participatory action approach 41 most research on illness narrative is based on textual data generated from written diaries surveys focus discussion groups and indepth interviews however qualitative data exist in other nontextual forms such as signs symbols nonverbal gestures paintings and other visual artifacts visual communication offers significant opportunities to explore lived experience and the subjectivity of patients illness experience 27 this is particularly relevant for patients with diabetes that puts them in awkward social situations such as having to inject a needle before a dinner date and having to worry about telling a blind date that one has a disease that is not curable as patients tell their story they untangle their illness experience and begin to accommodate to life as the person they have become based on this discussion this article presents a qualitative analysis of diabetesrelated images on tumblr and explores how patients use tumblr in the context of expressing their illness our study informs how visual social media sites can be developed to effectively enhance patients illness experiences and help stakeholders such as providers and caregivers to better understand the patients perspective leading to improved patient care methods data collection first the author searched the term diabetes on tumblrcom which resulted in posts associated with the tag diabetes tumblr shows 15 posts on the first page and shows more posts as users scroll down the search was repeated multiple times for four months each time new images were found those images were recorded in a dataset because we were interested in understanding how patients expressed their illness experiences in visual narratives we collected only those posts that contained images if the post contained images showing only text embedded in an image file the image was still included as our data we captured the images and the text for each post posts that only included text or videos but not images were not captured as a result we collected 295 posts comprising photos illustrations cartoons drawings and images with embedded text all posts were deidentified during the collection we did not record the poster information and other metadata including reblog and like counts due to the scope of this study being exploratory we focused our data collection and analysis on the images as units of analysis data analysis we analyzed the images from tumblr using open coding analysis 42 we chose this method to identify emerging themes and patterns of an unknown phenomenon the codes were iteratively refined and grouped using an affinity diagram 43 to make linkages among themes categories and subcategories the method allowed us to understand the social construction of illness experiences expressed by the posters additionally the analysis provided an alternative understanding of patients beliefs and actions that may vary from those expressed in a clinical setting 43 we asked the following questions during the analysis 1 what is portrayed in these images 2 what diabetesrelated problems are highlighted in the images 3 how does the poster cope with the problem if any 4 what are the distinctive characteristics across the images 5 what constrains or facilitates the process of disease management with these questions in mind the author began the descriptive coding translating the visual images into a textual description of what each image contained using atlasti qualitative software the textual data were also coded using open coding schema next the first author moved on to interpretive coding identifying possible causes implications and connections among the images by iteratively comparing images and codes produced from the descriptive codes the author then conducted axial coding attempting to find emerging themes of clusters and connections among the codes for eight months the author regularly discussed and debated the concepts and themes arising from data with a team of researchers once a month at research meetings the meetings comprised graduate students and a faculty member with expertise in health and risk communication communicative science and disorders games and humancomputer interactions the author solicited feedback from the group on the interpretation of the images gaining consensus on balancing interpretation with a more objective view of what each image conveyed relative to the posters illness experiences comments and questions generated from this process provided further avenues for reflection during the analysis the quotes from the textual images appear in italics with double quotation marks throughout the article results finding 1 the beginning tumblr users posted metaphors body images illustrations cartoons selfies photoshopped images memes and photographs of their daily experiences these images expressed their frustration of accepting diabetes as part of their lives dealing with fluctuating emotional and physical challenges along with the determination to manage their illness acceptance of diabetes as a chronic illness tumblr users posted revelations about how long it took to embrace both the good and the worse parts of living with diabetes seeing other tumblr users go through similar situations helped them to move on to accepting the disease one post stated it is never really been easy to talk about diabetes to other people but i have come to realize over time that diabetes has become a big part of me its been the greatest part and the worst part but its something that i cant change here the quote illustrates the posters coming to agreement with the greatest and the worst parts about having diabetes as a major life transformation another poster after spending 15 years with diabetes accepted the fact that im a diabetic and stated how finding this blog has helped so much and knowing others struggle the same as i do was reassuring similarly another poster stated i have never met an immature diabetic we have all had to grow up and face lifes reality one poster talked about learning from the past when injecting insulin was a big deal which has now become a peace of cake the images of these posts showed peoples perceptions about the self and the illness transforming overtime finally leading to a lifelong commitment to the illness tumblr users posted metaphors body images illustrations cartoons selfies photoshopped images memes and photographs of their daily experiences these images expressed their frustration of accepting diabetes as part of their lives dealing with fluctuating emotional and physical challenges along with the determination to manage their illness acceptance of diabetes as a chronic illness tumblr users posted revelations about how long it took to embrace both the good and the worse parts of living with diabetes seeing other tumblr users go through similar situations helped them to move on to accepting the disease one post stated it is never really been easy to talk about diabetes to other people but i have come to realize over time that diabetes has become a big part of me its been the greatest part and the worst part but its something that i cant change here the quote illustrates the posters coming to agreement with the greatest and the worst parts about having diabetes as a major life transformation another poster after spending 15 years with diabetes accepted the fact that im a diabetic and stated how finding this blog has helped so much and knowing others struggle the same as i do was reassuring similarly another poster stated i have never met an immature diabetic we have all had to grow up and face lifes reality one poster talked about learning from the past when injecting insulin was a big deal which has now become a peace of cake the images of these posts showed peoples perceptions about the self and the illness transforming overtime finally leading to a lifelong commitment to the illness emotional and physical fluctuations tumblr images depicted the emotional fluctuations and physical symptoms that people with diabetes pass through on a daily basis for example one post expressed how people with diabetes find it hard to have a good peaceful sleep showing an image of a woman sleeping peacefully another post tagged as anger post described their weekly routine as no ugh why omg finally yes and ends at crying emotional and physical fluctuations tumblr images depicted the emotional fluctuations and physical symptoms that people with diabetes pass through on a daily basis for example one post expressed how people with diabetes find it hard to have a good peaceful sleep showing an image of a woman sleeping peacefully another post tagged as anger post described their weekly routine as no ugh why omg finally yes and ends at crying showing the constant challenges they face with diabetes throughout the week another poster expressed i hate my life and need to roll over and die another image showed that diabetes loves to complicate things in their life other posts showed similar feelings of frustration when they have important work to do or meet deadlines these images showed the emotional trauma and despair that diabetes patients pass through daily as they struggle to manage blood glucose measuring blood sugar takes a large part of diabetes patients everyday life this was evident through the substantial number of images about glucometers and insulin pumps in our data posters expressed several emotions surrounding the use of a glucometer for example anxiously waiting for the glucometer and the excitement upon finally receiving it reading the instructions and using the glucometer for the first time held particular importance in addition images conveyed the emotional state of waiting for the blood sugar number to appear on the glucometer and expressed feelings of extreme disappointment upon receiving a high blood sugar number for instance one image showed a glucometer screen displaying oh shit instead of the actual glucometer reading the images showed their constant fear of uncontrolled diabetes this image was related to another image showing the cartoon character sponge bob square pants depicting panic attacks and depression the findings consist of a mix of both excitement and despair depending upon the test results we realized that it is not only the physical feeling but also the emotional state of sadness upon receiving a low glucometer reading that adds up to their stress feeling low or high are critical indicators for tracking how well blood sugar is controlled feeling low happens when patients medications are overworked compared with the level of sugar in their blood patients need to take sugar as a remedy not to fall into shock diabetes patients can feel low at one point and high the next many posts expressed such fluctuating physical symptoms as contributing to fluctuating emotional states for instance a screenshot image of a fluctuating blood sugar monitor was coupled with the text a long day another image expressed the low sugar levels at night as similar to a frantic roller coaster when patients are low they want to keep sleeping sedated with sugar tired of the struggle and scared of the consequences some posts described the state of feeling low and attempting to take sugar as crawling on a desert trying to reach the kitchen when your blood sugar is very low we found strong indications of emotional burnout and fatigue in managing the illness throughout the day additionally there is no particular time of day when they could be feeling worse or better instead images related to feeling high and low appeared across the board at all times of the day determination to fight against diabetes tattoos emerged as a dominant theme in our data mainly as an expression of determination and hope these images included a tattooed text shape or design that captured their health condition the designs expressed emotions such as hope the cycle of life dependency on disease and expressions of staying calm while bravely surviving the illness one post read tatted up finally type 2 diabetes for five years now despite all difficulties posts shared encouraging messages and showed determination to keep fighting with the disease until its cure is found posts other than tattoo images also conveyed determination for instance a post showed comic hero characters such as insuman and captain glucose to keep them driven many posts compared improvements made over time and the associated pride with these accomplishments in sum the images portrayed their beginning journey as a diabetes patient starting with struggles and acceptance while continuously being challenged with emotional and physical fluctuations but being determined to stay healthy although posters often used symbolic metaphors that only insiders would understand the posters attempted to talk to the broader audience about how challenging it is to go through this initial phase of having diabetes finding 2 living with diabetes posters also expressed the need for others to understand the daily struggles of a person with diabetes we found several posts indicating that people with diabetes strongly wish others could feel their emotional and physical pain many images were shared about the misunderstandings and stereotypes associated with diabetes one post read dont tell me i am a bad diabetic you dont have diabetes you dont know how hard it is i try my best to manage what i didnt ask for healthcare 2022 10 x for peer review 7 of 14 to the broader audience about how challenging it is to go through this initial phase of having diabetes finding 2 living with diabetes posters also expressed the need for others to understand the daily struggles of a person with diabetes we found several posts indicating that people with diabetes strongly wish others could feel their emotional and physical pain many images were shared about the misunderstandings and stereotypes associated with diabetes one post read dont tell me i am a bad diabetic you dont have diabetes you dont know how hard it is i try my best to manage what i didnt ask for several other posts expressed a similar level of annoyance regarding when someone says too much sugar relates to diabetes or when people mix up type 1 with type 2 diabetes many posters tried to raise awareness regarding type 1 diabetes which is not limited to children only and it is not always caused by eating sugar i have type1 diabetes because i ate too much sugar a similar post showing what people with diabetes do not agree with stated you didnt care for yourself on the whole we found posters trying to clarify that there are no good or bad diabetes patients and that each patient is different in terms of acquiring and experiencing the illness speaking about the daily social interactions one post mentioned people with diabetes notice the kneejerk responses by others when they order lowcalorie food in a public space another post mentioned that people with diabetes feel bad and hurt when they are asked to check their blood sugar and strongly want other people to stop judging them overall several other posts expressed a similar level of annoyance regarding when someone says too much sugar relates to diabetes or when people mix up type 1 with type 2 diabetes many posters tried to raise awareness regarding type 1 diabetes which is not limited to children only and it is not always caused by eating sugar i have type1 diabetes because i ate too much sugar a similar post showing what people with diabetes do not agree with stated you didnt care for yourself on the whole we found posters trying to clarify that there are no good or bad diabetes patients and that each patient is different in terms of acquiring and experiencing the illness speaking about the daily social interactions one post mentioned people with diabetes notice the kneejerk responses by others when they order lowcalorie food in a public space another post mentioned that people with diabetes feel bad and hurt when they are asked to check their blood sugar and strongly want other people to stop judging them overall we found that people with diabetes react with hostility towards social control and pressurizing behavior of others with regards to diabetes information spread through mass media was found to be both helping and misleading for example posters mentioned that mass media spreads the misperception that blood sugar is correlated with anger one post mentioned a person with diabetes hearing from others you are not fat you dont look fat few posts touched upon the misperceptions that exist within the diabetes community such as the proper usage of flex pens vs syringe and the right way to inject insulin mass media have also helped raise awareness about diabetes for example one poster thanked news reporters for clarifying that daily soft drink intake increases diabetes risk on the whole we found a considerable portion of images posted on tumblr about massmediabased messages on diabetes we noticed that tumblr users aggressively responded to such misperceptions and showed a strong urge to clarify these misperceptions as much as they could interactions with friends family and providers tumblr images also included different ways a person with diabetes interacts with family friends and healthcare providers these posts revealed the close monitoring of their parents on the posters diabetes status which the posters took as sometimes excessive and sometimes supported for example one post mentioned when parents ask how you are doing i reply in numbers my friends dont understand what i said but my parents do another image showed parents with an insulin pump painted on their stomach as a gesture of support to their child who has diabetes other posts showed images of adolescent diabetes patients being panicked upon seeing high glucose readings but trying to hide this from parents a similar post stated sometimes when i act stupid my blood sugar is just fine so dont ask me to check it another post read my blood sugar is fine in fact it is perfect i am just really angry right now all these images expressed frustration and distress about the comments they receive from others who do not know about diabetes we found that posters strongly protested about being judged by others for having diabetes or not managing their illness tumblr users portrayed their friends as being unsupportive or uninformed about their diabetes status one image showed how posters illustrated their friends being the diabetes policemeaning that the posters felt that the friends judged the posters behavior one quote mentioned above illustrated that friends did not understand the diabetes conversation they have with their parents we also found images in which posters strongly opposed the misperception that a person gets diabetes because their parents did not take care of them few posters showed their gratitude towards parents and appreciated their help albeit overprotective in correcting their diet and exercise we also found posts related to interactions with healthcare providers for example some posts mentioned to avoid selfdiagnosis and consult a doctor if you think you have diabetes one image mainly talked about the perceived facial expressions of the doctor when he knows the a1c score overall we found a tendency of hiding diabetesrelated worries from both friends and family at the same time we noticed a silent want of support from diabetes patients they perceived their larger social circle as being unsupportive and ignorant to their real condition overall we found reluctance towards both friends and family members as the groups to open up to about their situation finding 3 selfreflection this section describes findings around tumblr images portraying the posters reflection about their illness this section describes the core value that illness narratives offerthe beliefs that patients have and how those beliefs drive their behavior rich historical stories of failure recovery and restoration and how those experiences built up who the patients are life past present and future our analysis of tumblr images found that people with diabetes expressed a profound view of both past and future about the illness in terms of looking to the past we found images about how their health had improved or worsened with time in many images patients expressed that they hate to think about past events that they do not want to remember we also found forwardlooking images in which people with diabetes expressed a mix of hope and distress one such post mentioned that distress is associated with how many more years one would have to live with diabetes especially in the absence of a permanent cure another image showed the garden of eden in heaven with a trees hanging fruits being insulin bottles overall we found a mix of bittersweet experience with regards to diabetes management it is not surprising considering the chronic nature of the disease however we think that feelings differ depending on the time spent with the illness although we could not assess the age of the person posting on tumblr we found indications that older patients seemed to have negotiated with their illness as they made an effort to maintain health and wait for better cures historical stories of failure recovery and restoration and how those experiences built up who the patients are life past present and future our analysis of tumblr images found that people with diabetes expressed a profound view of both past and future about the illness in terms of looking to the past we found images about how their health had improved or worsened with time in many images patients expressed that they hate to think about past events that they do not want to remember we also found forwardlooking images in which people with diabetes expressed a mix of hope and distress one such post mentioned that distress is associated with how many more years one would have to live with diabetes especially in the absence of a permanent cure another image showed the garden of eden in heaven with a trees hanging fruits being insulin bottles overall we found a mix of bittersweet experience with regards to diabetes management it is not surprising considering the chronic nature of the disease however we think that feelings differ depending on the time spent with the illness although we could not assess the age of the person posting on tumblr we found indications that older patients seemed to have negotiated with their illness as they made an effort to maintain health and wait for better cures we also found a strong sense of helplessness expressed in the images posted on tumblr such as expressing feelings of depression because of the restrictions imposed by the illness one such image showed that diabetes had defined their territory which is limited to the glucose test result explicitly the younger patients expressed added frustration of not being able to enjoy junk food which they loved so much one post expressed the same feeling of reliance and helplessness by relating diabetes with a voodoo doll controlled by strings in the hands of the disease and thinking of oneself as an insulin junkie for life some posts indicated that people with diabetes find it hard to believe that their whole life depends on the medical supplies in a pouch that continuously dictates their daily choices and actions some posts talked about the added complexity of diabetes when coupled with other illnesses such as the common cold overall we found that living on the terms and conditions defined by diabetes is particularly frustrating for diabetes patients we noticed that diabetes patients longed for the past when they had the freedom and liberty to enjoy food we also found images in which posters talked about accepting the disease as a permanent part of their life again with an understanding of there being no escape from its complexities they showed to console themselves by thinking that diabetes is a disease with a long lifespan and they can survive it even with lowfunctioning organs we found we also found a strong sense of helplessness expressed in the images posted on tumblr such as expressing feelings of depression because of the restrictions imposed by the illness one such image showed that diabetes had defined their territory which is limited to the glucose test result explicitly the younger patients expressed added frustration of not being able to enjoy junk food which they loved so much one post expressed the same feeling of reliance and helplessness by relating diabetes with a voodoo doll controlled by strings in the hands of the disease and thinking of oneself as an insulin junkie for life some posts indicated that people with diabetes find it hard to believe that their whole life depends on the medical supplies in a pouch that continuously dictates their daily choices and actions some posts talked about the added complexity of diabetes when coupled with other illnesses such as the common cold overall we found that living on the terms and conditions defined by diabetes is particularly frustrating for diabetes patients we noticed that diabetes patients longed for the past when they had the freedom and liberty to enjoy food we also found images in which posters talked about accepting the disease as a permanent part of their life again with an understanding of there being no escape from its complexities they showed to console themselves by thinking that diabetes is a disease with a long lifespan and they can survive it even with lowfunctioning organs we found images in which people appreciated the invention of insulin but with the recognition that it is not a replacement for a fully functional pancreas images depicted the reality of being used to insulin shots daily monitoring and pricking with the realization that it is not getting any easier with regards to reactions towards glucometer readings we found posters expressing optimism to keep the morale high and hope for a better score in the coming months on the whole we found that people with diabetes are fully aware of the fact that their illness is without cure and that it may become worse if they do not put in concerted effort to control it with regards to diabetes management we found images related to routine daytoday activities and their impact on the illness for example one poster mentioned that working from home is particularly helpful for a person with diabetes a post about medication intake mentioned that unlike other illnesses diabetes patients do not have a fixed time for medication because it depends on their glucometer reading and daily fluctuations in the sugar level one post was about the extra space needed to carry diabetes supplies such as medicines and the glucometer few posts talked about the challenge of having to inject insulin in a moving vehicle another image showed insulin injection as an old longtime friend with regards to educating newly diagnosed patients one post explained the difference between cgm and an insulin pump by clarifying that cgm measures blood sugar levels and not insulin selfperceptions about body shape and organs the images posted on tumblr also showed how people with diabetes might view their physical body and internal body organs especially stomach and pancreas in the context of the illness one image showed that people with diabetes tend to treat their body as a very sacred place such as a temple and critically reject the views of treating it as trash where one can just throw anything other posts showed that people with diabetes idealize a very smart and slim body one post talked about the color and size of the insulin pump because this determines its placement on the body and also the effect on the choice of clothing in the case of the stomach images showed insulin pumps pasted with tape one post showed a patient filling out a drivers license form and not checking the field for organ donation of the pancreas other posts showed a healthy body but a dead pancreas such posts expressed emotions associated with sadness because the pancreas does not perform as well as other body parts another image showed a cartoon character talking with his pancreas and saying diabetes you will not compromise recovery from these posts we found that people with diabetes are very conscious of their physical changes and how the illness affects their perception about their physique and perceptions of smartness it is not surprising that the pancreas and insulin production remain a dominant thought on the minds of diabetes patients thus anything related to pancreas either on mass media print advertisements or news immediately catches their attention additionally diabetes patients stay on the lookout for more ways to paste the insulin pump on their body the stomach is the most used place for this because it hides the pump under the clothing discussion the ultimate goal of this study is to examine how visual illness narratives can be used to help various stakeholders such as peer patients health professionals researchers and caregivers to better provide support for patients we learned that microvisual illness narratives provide a rich medium for tumblr users to express struggles share help and reflect in depth the images triggered productive conversations about posters illness experiences that we might have not otherwise captured elsewhere below we discuss how visual narrative illness extracted from tumblr images provide utility and implications around patient care chaos quest and restitution narratives of diabetes in his book the wounded storyteller body illness and ethics frank classified three broad categories of illness narratives ie restitution chaos and quest narratives based on these classifications we elaborate on the illness narratives found on tumblr first chaos narratives are disjointed and without temporal sequence tumblr images showed posters progress in their diabetes management to fluctuate between sick vs worse no matter how hard they tried to maintain it as a result posters showed signs of despair and loss of hope chaos narratives describe experiencing illnesses with no cure andor unreliable treatments patients suffering from chronic illness find listening to chaos narrative helpful because they no longer feel alone patients with experiences associated with the narrative are often not in a position to fully articulate their condition accordingly chaos narratives are difficult to retrieve from patients close family members and friends mostly witness such narratives however through tumblr images the public could witness chaos narratives around posters earlier struggles and acceptance of the illness the narrative depicted anxiety frustration and distress from illness it revealed vulnerability and weaknesses which most people hide thus helping us understand the more indepth subjective side of the illness experience quest narratives are about patients fighting back these illness narratives consist of stories about patients strong will and making a concerted effort to fight the disease accordingly the narrative includes signs of improvement quest narratives also depict alternative ways of being well by focusing on how to live longer and healthier we found quest narratives to be most commonly appearing after chaos narratives on tumblr patients quest narratives consisted of images showing efforts to manage the diet perform regular physical activity and showing a positive attitude towards life even though pricking emerged as one of the most painful aspects of patients life even when posters showed signs of resilience and commitment to get better restitution narratives point toward the belief that health is restorable these narratives are stories of the recovery and restoration to better health for example in the past i was healthy today i have an illness but i will be healthy again tomorrow the restitution narrative originally denotes recovery the connection between the restitution narrative and our data was the hopefulness and positive attitude of posters for instance images showed recovery and improvement in maintaining the glucose level performing physical activity controlling the diet battling temptations to eat sugary food and managing stress with a sense of optimism and hopefulness for the future self these images provided insights about the everyday matters of people with diabetes and subtle realities that they may not openly disclose in a clinical setting tumblr also provides users with an opportunity to express aspects of their illness that may be considered taboo to openly share such narratives can open up conversations about sensitive topics that many want to talk about but never find the opportunity to do so implications for stakeholders and chronically ill patients tumblr images with the diabetes hashtag showed rich expressions of diabetes illness narratives the images communicated the anxiety frustration and vulnerability of posters who might have found it difficult or not appropriate to easily express such emotions in an offline social setting we also found stories of hope and struggle in which posters were seen facing the illness with a strong will to get better such narratives consisted of posters who made a concerted effort to fight the disease and showed enormous signs of improvement these images also showed alternatives ways of being well by focusing on how to live longer and healthier under the existing health conditions social media are increasingly becoming mostly visual media and enormous possibilities exist to utilize these data for prosocial benefits our analysis contributes unique insights about how diabetes patients selfdisclose their illness narratives and experience on tumblr patients and researchers can use the data to understand patients experience follow ones trajectory of illness and emerging trends by predicting possible outcomes from a patients current physical and emotional state for instance we can use crowdsourced tags metadata of images and automated visual analytic technologies to group images showing struggles success tips and selfreflection these groups can be used to provide tailored help to peer patients going through struggles posters can be matched as recommended friends to provide peer help if they post about similar emotional distress status researchers can use these images to understand emerging trends in a crosscultural context currently tumblr posters are predominantly westernoriented however with time tumblr membership may grow to include other nationalities thus providing even richer insights for diabetes management in an international public health setting research organizations such as the center for disease control and the national cancer institute can benefit from these findings to formulate funding announcements employing visual illness narratives on social media to better understand and serve the diabetes community during the analysis a strong sense of disapproval was found towards the social stereotypes and misunderstandings about diabetes in the tumblr community we suggest that this topic be brought into discussion by healthcare providers during hospital visits and counseling sessions to provide patients with an opportunity to express and build strong patientprovider relationships in addition diabetes support groups and community health educators can use this information for community engagement and for supporting existing health education interventions for instance patients with speaking disabilities or limited english proficiency may find it hard to verbalize their illness experience such patients can be shown visuals to use as a medium for expressing their concerns and questions additionally the findings of this study can contribute to the design and development of glucometers insulin pumps and future wearable devices for diabetes care we found specific emotional and physical behaviors associated with the use of these mobile devices that have implications in patients choice of clothing and preference for mobile devices for example children with diabetes may show specific resistance to wearing an insulin pump it is both uncomfortable and insecure for them to wear during school and play the findings can help design future devices which are more convenient and more comfortable to wear for all age groups the study findings also have implications for health marketing and advertisement we found that people with diabetes have a critical view of mass media advertisement specifically about food products a strong sense of skepticism and lack of trust was seen towards soda and sugary food manufacturers health marketers can use social media images to gain insights and design useful print and mass media advertisement and public service messages our study is not without limitations we do not know detailed information about the posters in terms of demographics and whether they were diagnosed patients our findings are instead based on the analysis of the images that the posters shared on tumblr interviewing the tumblr posters of these would help us to further understand how our interpretation differed and matched with the posters intention our next step is to involve healthcare providers caregivers and patients to extract their interpretations of these images this process could unveil hidden communication breakdowns and hints for improving patientprovider relationships funding this research received no external funding institutional review board statement the study was approved by the institutional review board at michigan state university irb i047709 informed consent statement the study only analyzed publicly available images and no interaction with human subjects was involved data availability statement the images used in the analysis are embedded within the manuscript all data used in the study is publicly available on tumblr

diabetes is a chronic illness affecting over six percent of the global population visual social media sites such as tumblr provide a unique opportunity to understand visual illness narratives of type 1 and type 2 diabetes and its effects on mental health we qualitatively analyze 259 tumblr images with a diabetes hashtag the results provide rich insights into the lives of diabetes patients including personal and social life interactions visual narratives portraying ones acceptance and maintenance of diabetes difficulty in social interactions and how patients identity and beliefs are shaped by the daily struggles and failures of living with diabetes we discuss the findings in the context of the chaos quest and restitution narratives of illness proposed by arthur frank the results have implications for the visual representation of chronic diseases on social media and for improving patientprovider interactions and treatment of type 1 and type 2 diabetes patients

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introduction there is considerable public political and philosophical debate about the provision of assisted reproductive technologies such as in vitro fertilisation particularly where these services are to be funded through state supported healthcare systems and general taxation 2729 in this paper i consider the exclusion from fertility treatment of obese people i discuss a number of potential justifications for a policy of refusing publicly funded ivf provision to obese people and argue that the reasons healthcare providers claim motivate such a policy do not do the justificatory work required i offer an alternative explanation for such policies relating to the responsibility obese people may bear for their subfertility i consider how we might begin to explore whether it would be appropriate to limit ivf access for those who are obese on the basis of responsibility and highlight some problems with such an approach to healthcare provision for the purposes of this discussion i shall largely focus on the united kingdoms healthcare system as an example the british system lends itself to assessment because of its quasicentralised structure it has explicit methods for addressing issues of resource distribution centrally with final decisions about service provision at the regional level made by local commissioners however much of the discussion is relevant to other national contexts where decisions about equitable provision of healthcare must be addressed policy guidance and exclusion of people with obesity in the uk guidance about what treatments and services should be provided through the nhs is produced by nice the role of nice is to synthesise relevant evidence and consider whether particular treatments provided to particular patient populations will provide sufficient health gains given their cost to make their funding justifiable given the other demands placed on healthcare resources i will discuss further in a later section the procedures nice uses for this purpose the guidance that nice provides is advisory final decisions about what treatment will be provided and to whom are determined by local commissioners relating to subfertility and the provision of ivf nice recommends that local commissioners should offer three cycles of ivf to women under the age of 40 who have unexplained subfertility and have not conceived after 2 years of trying through regular unprotected heterosexual intercourse the guidelines recommend that women aged 4042 should be offered one cycle of ivf the recommendations for specific diagnosable causes of subfertility differ from those relating to unexplained subfertility which is reported to affect somewhere between 10 and 40 of couples with subfertility 32337 for much of this paper i will be concerned with treatment for unexplained subfertility for which ivf is the main available intervention nice provide further guidance relating to alcohol consumption smoking caffeinated beverages obesity low body weight tight underwear occupation prescribed overthecounter and recreational drug use complementary therapy and folic acid supplementation some of these factors are thought to affect fertility in various ways and can influence the way treatment is provided i will focus on obesity here but it could be that some of these other factors warrant similar scrutiny regarding obesity nice state women who have a body mass index of 30 or over should be informed that they are likely to take longer to conceive… women who have a bmi of 30 or over and who are not ovulating should be informed that losing weight is likely to increase their chance of conception… women should be informed that participating in a group programme involving exercise and dietary advice leads to more pregnancies than weight loss advice alone… men who have a bmi of 30 or over should be informed that they are likely to have reduced fertility… 34 pp 1516 it is worth noting that nice guidelines do not explicitly advise against providing ivf to women with obesity they only flag that obesity may impact fertility and recommend providing certain weight loss advice to those women a report written by the national infertility group for scotland however does make specific recommendations that women with a bmi over 30 should not be offered fertility treatment 30 in fact commissioners responsible for determining what nhs services will be available for local populations invariably impose a bmi limit for treatment and independent units which provide fertility services both privately and for the nhs also often impose a bmi limit of their own 59 the bmi limit is imposed by almost all ccgshealth boards and generally requires that womens bmi be 19 or over and under 30 or 35 often for at least 6 months prior to receiving ivf 910 1 in addition some commissioners impose a bmi limit on the male partner of a couple wishing to access ivf 6 my focus in this paper will be on the upper bmi limit as applied to women similar criticisms are likely to be even more applicable to restrictions placed on male bmi but i set these aside along with the lower bmi limit placed on women seeking to access ivf the approach in the uk is comparable to a number of overseas contexts the royal australian and new zealand college of obstetricians and gynaecologists have published guidance that a bmi over 35 should be regarded as an absolute contraindication for ivf 5657 in the absence of professional body guidelines a 2016 survey of providers of fertility services in the united states found that the majority of responding centres have a formal policy of setting a maximum bmi threshold for ivf 18 a draft report from the canadian fertility and andrology society does not recommend imposing a bmi cutoff though notes that there is significant appetite for this and that a 2014 survey of canadian medical directors found that 50 of respondents imposed a cutoff 724 what is the justification for imposing an upper bmi limit on women seeking to access ivf services in the following sections i will consider a number of bases for deeming it appropriate to exclude obese people from nhsfunded ivf proposed justification i ivf is futile for obese women one basis for refusing ivf to obese women could be that it confers no clinical benefit medical futility is a contested concept insofar as judgements of futility often differ between different groups as well as between individuals this is significantly due to the fact that these different groups may value different things or be willing to tolerate different degrees of risk sideeffects benefits etc in deciding what treatments count as worthwhile without fully specifying what will constitute futile treatment in the case of ivf we might specify some parameters this will include most clearly treatment that is known with certainty will not result in the birth of a living child 2 it is likely that we should extend this to include treatment that is vanishingly unlikely to result in the birth of a living child in addition to considering the rarity of benefits conferred we should also consider the costs associated with the treatment and begin to incorporate these into an assessment of whether or not ivf is likely to be of clinical benefit as well as considerable financial costs ivf is associated with a number of harms one such risk is developing ovarian hyperstimulation syndrome which can result from taking drugs to stimulate egg cell production and in rare cases can be fatal other procedures associated with ivf as well as the risks associated with pregnancy and childbirth in general should be considered as detracting from the net benefit of ivf thus it might be appropriate to refuse treatment where there is a nonzero chance of a live birth resulting but a reasonably high risk of serious sideeffects such that the net effect is very likely to be negative obesity is a risk factor for subfertility and obese pregnancies are associated with higher risk of complications that threaten the health of the mother as well as reduce the likelihood of a live birth and potentially the longer term health of the child born 243451 however it seems unlikely to be appropriate to describe ivf treatment as futile in obese women but not nonobese women as described by tremellen et al 57 analysis of a large sample of cycles in north america showed live birth rates in morbidly obese women were not much lower than in women in the healthy weight range proposed justification ii ivf is insufficiently costeffective on any healthcare system there are likely to be strong objections to the provision of medically futile treatment i have shown that current evidence suggests ivf is not necessarily futile in obese women and so this does not seem an appropriate justification for excluding them 1 3 health care analysis 276176 from treatment for a nationalised healthcare system such as the nhs the need to fairly distribute finite resources requires that justifiable treatments are not only not futile but that they be sufficiently costeffective in this section i will summarise how costefficiency is judged within the uk healthcare system and argue that it is inconsistent to judge ivf provision for obese women to be costinefficient whilst judging ivf provision for nonobese women to be costefficient rather than showing that ivf in obese women is costeffective my claim here will be that the procedures used to judge costeffectiveness in the context of ivf are inadequate and that there is probably insufficient evidence at present to make a reliable judgement regarding the costeffectiveness of ivf in either obese or nonobese women the gold standard of evidence in evidencebased medicine is the randomised controlled trial this takes a population of people allocates them at random to either the treatment or control group and compares the effects observed in the treatment arm with those in the control arm the significance of rcts is that if well designed and executed they provide a reliable way of assessing the causal effects of a treatment in the context of ivf this is particularly important because of the possibility of spontaneous conception which i will say more about subfertility is typically defined by failure to conceive following a period of regular unprotected heterosexual intercourse subfertility can also be diagnosed in the presence of a clear subfertilitycausing factor such as where the individual is known to have undergone sterilisation or lacks viable gametes a diagnosis of subfertility according to the oneyearwithoutconceiving definition does not indicate that a couple cannot conceive without assistance but rather it indicates that they have lower fertility than those who conceive within a year hence why i prefer the term subfertility to infertility since the latter is erroneously suggestive of sterility the most likely time to conceive is within the first month of trying with each subsequent month conception becomes increasingly less likely within the first year of trying 80 of couples will conceive through intercourse of the 20 who do not conceive in the first year of trying 50 will conceive during the second year of trying 38 this trend continues with decreasing numbers of people conceiving each subsequent year 1455 this means that if the population of people who did not conceive after 2 years of trying were all provided with ivf some of those who successfully conceive would have conceived anyway in the absence of ivf rcts allow us to estimate what additional proportion of people conceive in the presence of ivf and this is particularly important in the context of unexplained subfertility there is however very little good quality evidence relating to the effectiveness of ivf in people with unexplained subfertility a cochrane review 3 published in 2012 identified just six rcts looking at the effectiveness of ivf for treating unexplained subfertility 42 the authors concluded that the paucity of data meant it was not possible to establish how effective ivf is in fact only two trials compared ivf to expectant management of these one used live birth rates as the outcome measure 16 whilst the other used pregnancy rate 52 the former reported a strong effect of ivf and the latter a negative effect when put together they indicate that ivf slightly increases the chance of pregnancy in women with unexplained subfertility however the authors stopped short of including this in their conclusion due to the small sample sizes different outcome measures and other limitations of the evidence the human fertilisation and embryology authority the uk regulatory body for fertility clinics reports the success rates of ivf as ranging from a high of 29 to 2 17 however these data do not take into account spontaneous conception and so only provide half the picture of ivf effectiveness if the restriction of ivf to people with obesity is to be justified on the basis of it being insufficiently costeffective whilst ivf is still provided to those who are nonobese then this should be established through evidence of acceptable quality that establishes the costeffectiveness of one and the costineffectiveness of the other the above serves to show that the quality of the evidence relating to effectiveness of ivf in general is very weak to assess costeffectiveness nice combines evidence about the effectiveness of an intervention with evaluations of the benefitsharms that result from that intervention and the cost of providing that intervention in order to compare across different kinds of healthcare nice uses a common currency the quality adjusted life year nice gathers available evidence about the effectiveness and cost of a given treatment or intervention and uses this to estimate to what extent that treatmentintervention is likely to increase someones length and or quality of life and at what cost one qaly is equivalent to a year of life in perfect health so if a particular drug extended someones life by 15 years and during that time they experienced an average health state of 05 then that drug would create 75 qalys if that drug cost £10000 a year then the cost per qaly would be £20000 whilst nice maintains that they do not put a price on human life as such they tend to use a limit of approximately £20£30 k per qaly for a treatmentintervention to be considered costeffective 35 there are various ways in which exceptions can and are made to this limit including for instance endoflife care 19 nices use of qalys is somewhat contentious attracting criticisms relating to both the theoretical possibility of capturing all of the heterogenous benefits of a treatmentintervention in a single measure as well as substantive criticisms of how qalys overunderweight particular kinds of health and healthcare 39 on the whole however it might be reasonable to accept the flaws 1 3 health care analysis 276176 associated with qaly use in preference to alternative less systematic approaches to rationing healthcare resources in the context of reproductive technologies qalys become much more complicated in the 2004 guidelines for provision of fertility treatment nice states there is an important debate about whether the outputs of assisted reproduction can be incorporated into a measure than can be compared with other uses of the same resources it is not logical to try to derive a qualityadjusted lifeyear measure from live births arising from ivf sic 31 p 6 despite this hesitancy nice subsequently commissioned a report into the economic modelling of qalys in subfertility treatment a dubious feature of this modelling is that it only counts the improvements in quality of life postfertility treatment that attach to the female partner receiving ivf ignoring both the qalys gained by creating a life and those experienced by the recipients partner this is clearly an important decision since to include the qalys attaching to the life created would presumably make ivf treatment hugely costeffective it might also however direct healthcare spending down the path of the repugnant conclusion the modelling involved in calculating the costperqaly for ivf is complex needing to take account of the ways in which for instance providing treatment at different time points influences the number of qalys accrued over a lifetime the varying costs of ivf depending on provider the potential need for additional healthcare due to pregnancy and childbirthrelated complications and so on 38 4 the results of this modelling are presented showing variations along a number of different dimensions for instance the authors calculate how costeffectiveness varies with maternal age whether one or two embryos are implanted during treatment whether it is the first second or third cycle provided to that individual and whether the willingnesstopay threshold is set at a costperqaly of £20 k or £30 k the results of such calculations can sometimes be odd recommending islands of treatment in translating these calculations into guidelines nice must smooth out such oddities none of the costeffectiveness calculations published in the national collaborating centre for womens and childrens healthnice report indicate how obesity is expected to impact the costperqaly of ivf provided to obese women this is not to say that there is no way of estimating how obesity could affect the costeffectiveness of ivf papers by pandey and bhattacharya 40 pandey et al 41 koning et al 21 tremellen et al 57 and mahutte et al 24 all argue that there is insufficient evidence showing the detrimental effect of obesity on the success of ivf compared to nonobese recipients to justify restricting treatment to obese women this does not mean that obesity has no impact on costeffectiveness of ivf treatment nor that weight loss is not a desirable occurrence in obese women prior to pregnancyivf treatment instead it indicates that the current policy of commissioners in the uk is not based on rigorous assessment of costeffectiveness and a judgement that whilst ivf provided to nonobese people falls above the threshold for costeffectiveness provision to obese people falls below that threshold proposed justification iii something else so far i have considered two potential justifications for excluding obese women from accessing ivf first that ivf is futile in obese women and second that ivf is insufficiently costeffective to warrant funding in the context of a healthcare system which is required to ensure that a finite budget is spent efficiently i have rejected these arguments on the basis that they rest on dubious extrapolations from the available evidence recall my claim is not that it is costeffective to provide ivf to obese women but that there is insufficient evidence to show that it is significantly less costeffective than to provide it to nonobese women many commissioners in the uk do provide ivf to nonobese women but exclude obese women to claim that evidence relating to the costefficiency of ivf allows for finegrained distinctions between different points on the bmi scale when so little is known about numerous aspects of the effectiveness of ivf is at best naive and at worst intentionally misleading i now wish to consider a further possible motivation for excluding obese women from access to ivf this is the suggestion that those who are responsible for their ill health should be deprioritised for treatment relative to those who are not responsible for their ill health my claim will be that it is plausible that judgements of responsibility play an implicit indirect role in policies which exclude obese people from ivf i will not argue that this is the case since establishing this would require further empirical work i will comment on whether such a responsibilitybased motivation is likely to provide justifying reasons for restricting ivf in this way financial pressure on the uk healthcare system particularly since 2010 has resulted in changes in the way services are rationed 20 in 2015 the uk government announced the nhs spending review for the next 6 years which required nhs england to undertake £22 billion in efficiency savings over that period 31 unsurprisingly this has led to a reduction in the provision of services for a number of groupsconditions fertility treatment is one area which has seen significant shrinkage in nhsfunded provision the campaign group fertility fairness reported in 2017 that the number of ccgs in england offering the nicerecommended three cycles of ivf to women who met eligibility criteria halved between 2013 and 2017 going from 24 to 12 of ccgs they also reported that 23 of ccgs in 2017 offered two cycles 61 offered one cycle and 4 offered no funded ivf at all 9 3 health care analysis 276176 ivf may be a relatively easy target for commissioners looking to cut costs by reducing service provision evidence is mixed pronatal social norms often dominate resulting in stigma attaching to those who remain childless 582844 and this might be expected to result in general support for those requiring assistance to have children there is however also evidence that people do not generally think of subfertility as a disease and this may limit the extent to which treatment for subfertility is seen as a priority for resource allocation within healthcare 28 attitudes towards obese people are more decisively negative researchers have found extensive evidence of stigma directed towards obese people in a number of contexts leading to disadvantage rebecca puhl and colleagues have described the pervasive effects of stigmatisation of obesity in a number of contexts including healthcare settings the workplace educational institutions and interpersonal relationships 45 46 47 they report how physicians surveyed associated obesity with poor hygiene noncompliance hostility dishonesty a lack of selfcontrol and laziness nurses dieticians and medical students have also been shown to form negative associations of obese people 45 pp 792795 in the workplace employers tended to see obese people as less desirable employees overweight applicants were judged as significantly less neat productive ambitious disciplined and determined they were assumed to be lazy less conscientious less competent disagreeable and emotionally unstable they were also thought to have poorer attendance records and to be poor role models perhaps as a consequence obese people tend to earn less are less likely to be promoted and more likely to get sacked than their nonobese counterparts 45 pp 789792 children rate obese children as those they would least like to be friends with obese high school students in a us sample were less likely to be admitted to college than nonobese students with equivalent academic performance obese students tended to receive less financial support from their families than nonobese students 45 pp 795797 i have argued that the futility and costefficiency based justifications for excluding obese people from accessing ivf are weak i think it is at least plausible perhaps likely that such decisions by commissioners are influenced by first a need to make savings somewhere due to financial constraints and second an assessment of public sympathy towards the recipients of certain servicesthe value of providing those services given the highly stigmatised nature of obesity the ambiguity around the status of subfertility as a disease and the confusion around the methodologies used to assess its costeffectiveness it is unsurprising that ccgs have chosen to deny ivf treatment to obese people fertility treatment may not be an isolated example a report by the royal college of surgeons criticises the restricted provision of elective surgeries for those who are obese or smoke 48 i take it that excluding some people from healthcare treatment that is available to others on the basis of stigma and moralisation would be impermissible and contrary to the spirit of the uk system of healthcare provisioninformed by procedures such as qalyassessmentas well as systems of healthcare distribution elsewhere however whilst the the equality act 2010 outlines protected characteristics which must not form the basis of discrimination there is no specific provision made for obesity or more broadly physical appearanceattractiveness beyond race disability or sex 8 there have been cases of successful legal action for discrimination relating to obesity on the grounds that the individuals bodyweight constituted a disability but these are rare and do not reflect either an assumption that obesity generally qualifies as a disability nor that a legal protection against obesitybased discrimination exists similarly the nhs constitution repeats a commitment to delivering healthcare that does not discriminate on the basis of those protected characteristics described in the equality act 2010 yet it makes a number of additional commitments based around guiding principles and values to for instance treat all available to need meet the highest standards of excellence and professionalism to put the patient at the heart of nhs activities to treat people with respect dignity and compassion 32 such commitments do not appear compatible with institutionalised discrimination and stigmatisation of people with obesity thus if part of the explanation for why obese people are excluded from accessing nhs funded ivf treatment is that they are a soft target for cost cutting there would be reason to object to the behaviour of commissioners complicit in this systematic discrimination i cannot establish that this is the case here but have instead sought to show that the evidentiary basis of this policy is weak that healthcare commissioners are under severe financial pressures and that both fertility treatment and obese people may be publicly unpopular some might argue that there is a relevant difference between those who seek ivf and who are a healthy weight and those who are obese in the next section i will briefly consider whether responsibility might ground a justification for excluding obese people from accessing nhsfunded ivf responsibility obesity and subfertility it is a widely shared intuition that the consequences of peoples behaviour should track responsibility although questions about what exactly responsibility requires and how it relates to free will and determinism remain disputed 3654 this can reflect both benefits and harms people should reap the rewards as well as bear the burdens of their behaviour responsibility is a perfectly normal feature of many areas of life including personalsocial relationships criminal justice policy employment practices sporting achievements and so on the requirements and implications of responsibility can be analysed in a number of ways a common distinction is drawn between causal and moral responsibility with the former identifying the causal role an actor played in bringing about some consequence and the latter typically identifying a deeper relationship between an agent and a consequence often resulting in responses such as praise or blame it is the presence or absence of moral responsibility for some consequence that is often used to determine how it is appropriate to treat an agent when we seek to hold her responsible it is common to identify two broad conditions for moral responsibility the epistemic and control conditions the first requires that the agent could foresee the consequences of her actions she understood how her behaviour would 1 3 health care analysis 276176 impact the world the second requires that the agent be able to control her actions she could have behaved differently some version of these conditions has been incorporated into most accounts of moral responsibility since aristotle though the exact demands vary 112 it is not clear how we should go about developing a systematic means of assessing whether or not an individual was responsible for some behaviour there are however cases which bookend the spectrum of responsiblenot responsible for instance if i am sitting quietly reading a book when a remarkably strong gust of wind dislodges me from my chair and causes me to collide with you injuring your arm it seems clear i should not be judged morally responsible for your broken arm i was not an active agent in this event and we should not call my colliding with you an action of mine in contrast if upon spotting you i discard my book and leap from my chair and purposefully attack you with the full intention of breaking your arm then it seems clear that i am morally responsible for injuring you turning to the current case the challenge is to consider whether or not those who are obese and subfertile should be considered morally responsible for their subfertility evidence suggests that awareness of the impact of obesity on fertility is limited though that does not mean all of those who are obese and subfertile were unaware of the fertilityrelated risks of obesity intuitively obesity seems under individual control however evidence from diverse research programs including work identifying the social determinants of health and the psychology of behavioural control suggests it is often extremely difficult for individuals to make changes to their lifestyles that result in significant weight loss 252653 further it will often be unclear whether a particular individual who is both obese and subfertile is subfertile because of her obesity the causal role of obesity will be underdetermined at an individual level it is beyond the scope of this paper to make any kind of estimate as to the proportion of people who are both subfertile and obese who sufficiently fulfil the epistemic and control conditions of responsibility to be considered morally responsible for their subfertility however it seems reasonable to assume that there exist both people with subfertility who were oblivious to the effect of obesity on fertilitylacked control over their obesity and people with subfertility who were aware of the effect of obesity on fertilitypossessed control over their obesity thus in the population of obese people with subfertility there will be some mix of morally responsible and not morally responsible individuals if responsibility were to be incorporated into decisions about ivf provision it would be necessary to distinguish between those who were morally responsible for their obesitylinked subfertility and those who were not this would require delving into individual cases of subfertility and seeking a way of determining who is and is not responsible for their subfertility as well as being highly intrusive this would likely be financially costly what would be the payoffs of such an approach one possibility is that rationing ivf in this way would act as an incentive for people to maintain a healthy bmi it has been proposed by some that educating young people about the damaging effects obesity could have on their fertility is a potential tool for health promotion and weight loss 22 the payoff of this effect would be dependent on whether or not excluding obese people from ivf resulted in fewer people becoming obeseobese people losing weight to my knowledge no research has estimated the effect of bmirestricted ivf policies adopted by commissioners in the uk on obesity and from what is known about peoples attempts to lose weight it seems unlikely that denial of nhsfunded ivf treatment for obese women would have a significant positive effect on weight loss efforts 11 another consequentialist justification for bmirestricted ivf is that it reduces the number of people eligible for treatment and thus saves money however whilst discussions of healthcare allocation may often emphasise costsavings this should not be taken out of context the reason for saving costs on some areas of healthcare is so that those resources can be more effectively used in other areas of healthcare improving the costefficiency of overall provision if obese people can benefit from ivf then it makes sense to provide ivf to obese people another drawback of such a justification would be that it seems to arbitrarily limit some peoples access to healthcare finally justice based arguments might motivate bmirestricted ivf provision amongst those responsible for their subfertility the most demanding version of this claim relates to desert that it is a good thing in and of itself if people get what they deserve translated into the subfertility case this claim would imply that it is good for people who are responsible for their obesitylinked subfertility to be excluded from treatment and bad for them to receive treatment a weaker defence of bmirestricted state funded ivf policies would be broadly luck egalitarian this roughly assumes that as a matter of justice the state is obligated to assist those who experience bad brute luck but not those who experience bad option luck luck egalitarians may still assist people who experience bad option luck but this is not a requirement of justice and if it involves failing to assist someone with bad brute luck then it will not be permissible essentially luck egalitarianism could support a policy of prioritising treatment for those whose subfertility resulted from factors for which they were not responsible ultimately it must be considered whether such justifications for seeking to distinguish between those who are and are not responsible for their obesitylinked subfertility are sufficiently powerful to overcome the reasons for not drawing such distinctions as mentioned countervailing reasons could point to the difficulty of making such judgements and the likely intrusiveness involved the danger of further stigmatising certain disadvantaged groups and principled objections that healthcare 1 3 health care analysis 276176 providers just should not take account of responsibility when making allocation decisions conclusion in this paper i have advocated a sceptical stance towards evidencebased justifications for excluding obese people from nhsfunded ivf treatment i have argued that the lack of high quality evidence regarding the effectiveness of ivf in both obese and nonobese populations and the confusion around how qalys are calculated in relation to the outcomes of ivf give us reason to be hesitant in accepting the claim that this policy is justified on costefficiency grounds whilst ensuring the efficient provision of healthcare is an important function of the state methodologies such as evidence synthesis and qaly calculations must be applied with full acknowledgement of the degree to which these techniques incorporate numerous controversial assumptions and rough estimations and often must extrapolate from weak evidence claims that the evidence is of sufficient clarity to make decisive costeffectiveness cutoffs appropriate is disingenuous rather i propose that references to the costinefficiency of providing ivf to obese people may mask other influences such as negative attitudes towards obese people that render them easy targets for costcutting commissioners finally i introduced an alternative approach to justifying policies which exclude obese people from accessing ivf based on judgements of responsibility in addition to other factors whilst this discussion has been kept necessarily brief my suspicion is that such justifications would ultimately struggle to support a policy which required intrusive investigation into peoples disease aetiology and judgements of responsibility 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 publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

many countries tightly ration access to publicly funded fertility treatments such as in vitro fertilisation ivf one basis for excluding people from access to ivf is their body mass index in this paper i consider a number of potential justifications for such a policy based on claims about effectiveness and costefficiency and reject these as unsupported by available evidence i consider an alternative justification that those whose subfertility results from avoidable behaviours for which they are responsible are less deserving of treatment i ultimately stop short of endorsing or rejecting such a justification though highlight some reasons for thinking it is unlikely to be practicable

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introduction cervical cancer is a health problem occurring mainly in low and middleincome countries ranking second in incidence and third in cancer mortality among women it should be added that globally in 2020 882 of new cases and 914 of cc deaths were detected in these countries 1 these differences could be due to multiple factors the lack of coverage of vaccination programs and the limited efficiency of timely detection strategies to prevent this disease 2 in mexico cc is a health problem mainly in women of childbearing age in 2020 approximately 9429 women were diagnosed with cc representing 92 of cancer cases in women older than 20 years with cc being the secondhighest incidence in mexican women 1 the human papillomavirus is the leading risk factor for the development of cc the highrisk genotypes are hpv 161831333539455152565859 66 and 68 in mexico a positivity of 65 of the hpv16 and hpv18 genotypes was attributed to cc patients 3 other risk factors for low and middleincome countries cc include beginning sexual activity early having multiple sexual partners multiple pregnancies smoking using oral contraceptives and other sexually transmitted diseases also sociodemographic and socioeconomic status is an associated risk factor for developing cc 4 5 6 approximately 77 of cases in mexico are detected in locally advanced stages 16 in early stages and 7 in advanced stages the histology of the epidermoid type being the most frequent in 80 of cases 78 the highest mortality occurs in the countrys south mainly in states such as chiapas colima baja california tabasco and morelos 9 the characteristics of women who develop cc are very peculiar some of them are advanced age low income being indigenous immigrant having difficulty paying for screening studies having a low educational level lack of health insurance and inadequate medical coverage 1011 in 2003 the seguro popular was approved in mexico to provide free health services for some diseases for those without social security in 2005 cc was incorporated into the interventions with a high catastrophic expenditure covering screening and treatment for cc in this population aiming to have better screening and make the treatment of the disease more affordable for the vulnerable population 12 although there are studies in mexico and other countries on the sociodemographic characteristics of women with cc in mexico we seek to demonstrate that factors related to poverty impact survival in a population that is already marginalized and information on these factors need to be investigated therefore this study aimed to characterize the mexican population with cc and identify the sociodemographic variables that affect os methods this retrospective study included a cohort of women diagnosed with cc between january 2003 and december 2005 and followed until december 2016 at the instituto nacional de cancerología mexico city data were collected from the electronic and physical records at the incan patients ≥ 18 years of age with a confirmed diagnosis of cc through biopsy and a complete recordwith information on the clinical variables analyzed in this studywere included patients with all histological types were included at any clinical stage and in any functional state a total of 4631 cc patients were included the stage of the disease was defined according to the criteria of the international federation of gynecology and obstetrics 2003 and 2009 1314 the information from the questionnaire for the assignment of socioeconomic status to patients for payment of recovery fees to assign their socioeconomic status was used to determine the ses this questionnaire has been used in all the institutes of the ministry of health in mexico since 1995 15 the questionnaire is composed of 5 socioeconomic variables that comprise 100 of the score distributed as follows 55 family income 10 occupation 10 family expenses 20 housing and 5 family health the points obtained are added once the patients answered this questionnaire in the initial consultation the ses comprising six levels is assigned from level 1 to level 6 this questionnaire included variables that characterized the areas and housing where the patients lived the variables considered were the state of residence the place type of dwelling housing material ownership of the home number of public services included in the residence intradomiciliary services and number of people living in a bedroom of the home in addition the characteristics of the financial support network were recorded primary economic provider academic level of the provider and the percentage of revenue spent this percentage was calculated by considering expenses and income on the other hand sociodemographic variables were collected to understand better the ses of the patients such as age marital status educational level occupation and religion data associated with the general characteristics of the disease included karnofsky performance status 16 age comorbidities parity menarche age of onset of sexual life approximate time of onset of symptoms and histology as well as the characteristics of primary cancer treatment in the different stages of the disease the study was submitted and approved by the ethics and research committees of the incan statistical analysis descriptive statistics with medians and their minimum and maximum value or frequencies with their respective percentage were used the kaplanmeier test was used to obtain the cumulative probability of os at fifteen years referencing the time elapsed between diagnosis and death or the last visit recorded in the file the logrank test was used to compare the survival functions in the stratified variables for bivariate analysis the x2 or kruskalwallis test was used according to the distribution of the variables the variables that showed a statistical significance or tendency in the bivariate analysis were included in the multivariate analysis the multivariate analysis was performed using the proportional hazards model only the variables that had a statistical significance or tendency are shown interaction terms and proportionality assumptions were evaluated in the final model any probability of ≤ 005 was considered statistically significant twotailed statistics were used in all cases and calculations were performed with spss version 23 statistical software results we analyzed the sociodemographic characteristics of the 4631 women who met the inclusion criteria according to ses 386 were assigned to level 1 357 to level 2 213 to level 3 32 to level 4 07 to level 5 and 02 to level 6 women with ses levels 12 were classified as low ses while those with levels 36 were classified as high ses the median age was 51 years and significantly more patients with high ses were geriatric women with low ses were significantly younger at the time of sexual debut and had a median of 4 pregnancies with a maximum of 22 most of the women with high ses lived in urban areas while the more patients with low ses lived in rural areas no differences were observed regarding marital status half of the patients had no partner regarding the level of education 484 of the patients did not receive any education but 61 of patients with high ses received at least elementary education notably 785 of patients had no occupation which was consistent in both ses groups the primary economic provider was frequently the partner followed by adult progeny notably the revenue spent was a median of 80 for all patients and significantly higher for the low ses patients with a maximum of 1000 next we described the patients functional status and characteristics related to the disease and cancer treatment the karnofsky median score was 90 the most common comorbidities were high blood pressure which was more frequent in high ses patients and diabetes among other comorbidities renal impairment was reported in 9 of patients notably the onset of symptoms was more than six months in 40 of patients with low ses compared to 35 of patients with high ses 36 of patients with high ses had onset of symptoms of less than three months most patients were diagnosed at locally advanced stages with squamouscell carcinoma histology 122 of patients with low ses were diagnosed at advanced stages or relapsed or persistent disease compared to 105 of patients with high ses regarding treatment 537 of earlystage cc patients underwent surgery 576 of locally advanced cc patients received crt followed by bt and 486 of advanced recurrent or persistent cc patients received other treatments no differences in treatment were observed among those with low or high ses we performed a bivariate and multivariate analysis to identify the prognostic factors associated with os table 3 describes the variables that showed a tendency or were significantly associated with os we next performed the multivariate analysis having a karnofsky lower than 90 age younger than 60 living in a rural or suburban area having ses 12 the most advanced stages of the disease and not receiving cancer treatment were associated with lower os of the factors analyzed we found that the karnofsky performance status clinical stage of the disease and receiving treatment had the most impact on os we analyzed the survival of cc patients the mean followup for os in this cohort of patients was 49 years and the mean os was 137 years 207 of patients died from cc 23 died from other causes 206 were alive and 564 were lost to followup a significant difference in os was observed between stages we analyzed the patients lost to followup 202 of the lost patients did not even begin treatment these were over 50 years old with a karnofsky functional status score of less than 80 were diagnosed with more advanced disease stages were economically dependent had no partner and their income expenditure exceeded 80 discussion diagnosis of earlystage cervical cancer is imperative to increase the chances of curative treatment and survival sociodemographic characteristics may play a role in the timing of diagnosis and subsequent care of women with cc explanations for socioeconomic differences in survival are not well documented however the possible underlying causes can be separated into factors related to the tumor the patient and the healthcare system 17 few studies relate the ses of cc patients with os this study aimed to characterize the cc population and identify the sociodemographic factors associated with os our study observed that patients with cc belong to the lessbenefited population and that factors such as functional status age living in an urban area having a lower ses having an advanced stage of the disease and not receiving cancer treatment increased the risk of mortality some past attempts to explain social differences in cancer survival have focused on differences in disease stage at diagnosis 18 it has been estimated that between 68 and 77 of cc cases in mexico are diagnosed with las 78 other reports have similar findings to our study where os in the advanced relapsed and persistent stages is lower than in the early stages 81920 we confirm that the clinical stage is the strongest predictor of all clinical prognostic factors and a lower ses relates to a more advanced disease 21 studies show that women with lower ses are more likely to be diagnosed at an advanced stage 2223 because there is a lack of health insurance and factors related to the health care system the detection of cc is likely to be diagnosed in more advanced stages 24 25 26 this may be also related to less frequent visits to the doctor and lack of cc screening 27 on the other hand socioeconomic differences may impact diagnostic quality patients with lower ses may be misdiagnosed with localized disease while actually having a more advanced disease 24 we observed that the functional status of patients plays an essential role in predicting their prognosis a karnofsky score below 90 was associated with a lower os which was also reported in a previous study 28 a decrease in performance status may be linked to increasing age as studies have shown that individuals above 65 are more likely to have a karnofsky score below 90 28 our study found that patients over 60 had a lower os several other studies have reported that older age is associated with lower os regardless of the disease stage for instance women aged 50 to 69 have a risk index of 146 while those over 70 have a risk index of 287 making them more likely to receive palliative treatment or no treatment at all this finding is consistent with the results of our study 2829 previously it was demonstrated that comorbidities were associated with higher mortality after surgical treatment 3031 more so the presence of comorbidities is a factor that influences the decision of cancer treatment which may be related to os a retrospective study observed that comorbidities were a significant predictor of external rt reinforcement associated with lower os and more significant toxicity in las patients 32 in the present study comorbidities had no association with os a possible explanation is a subregistry of this information mainly in physical records education could be a factor related to opportune diagnosis and treatment for cc it was found that women with no education needed help understanding cc and their ability to cope with particular situations was impaired consequently the patients did not adequately comply with medical followup 33 a study in ethiopia described that having a lower educational level being young and being informed through mass media were associated with insufficient knowledge of the disease 34 in other latinamerican countries limited education was a factor related to cc mortality 27 although low education was frequent in our population it did not impact os evidence suggests that social support leads to better os 3536 possibly because better social support leads to timely seeking of an appropriate diagnosis and treatment 30 in this study just over half of the patients who attended had a partner whose key role was economic provider however having a partner was not a prognostic factor for os social support is less prevalent among disadvantaged or lowincome groups and if such factors impact survival they could contribute to socioeconomic differences 37 according to the results 168 of women lived in rural areas in other populations women who live in rural areas tend to delay their medical care more frequently than those who live in urban areas 31 38 39 40 a study in colombia reported higher mortality in women living in rural areas 41 in the southern region of mexico in the most marginalized states mortality rates from cc are higher than in the center or north of the country it should be added that for years the decrease in the mortality rate has been more significant in the center than in other regions 819 the differences in mortality between areas may indicate the ineffectiveness of the current health programs for reducing cc mortality throughout the country 19 surprisingly we found that patients in rural or suburban areas had higher os than those in urban areas explanations for this finding may be related to the urban lifestyle which includes the increased levels of psychological stress sedentarism obesity smoking and alcohol consumption that could impact os 42 an important finding was that receiving cancer treatment was associated with higher os which justifies the need to have all the infrastructure human and material fig 1 overall survival of cc patients according to disease status top kaplan meier graph shows cumulative survival in early disease locally advanced disease and advanced recurrent and persistent disease cc patients with a followup of 15 years bottom according to disease status the number of cc patients at risk at 5 10 and 15 years of followup resources to offer a quality therapeutic option to cc patients among the limitations of this study is that information was collected retrospectively and updates in the format to gather the information made it impossible to assign the ses to some patients another limitation was the high number of followup losses this patient loss is in line with reports from another study which mentioned that about 47 of patients with cc in mexico only attend one consultation and subsequently abandon their followup 8 finally there was no information from 2 states of the 32 that comprise the country and the number of cases per state ranged from 1 to 1496 among the strengths of this study is the analysis of various sociodemographic variables that impact os in cc patients likewise there were few excluded cases which makes the results applicable to the clinical setting conclusions belonging to a low ses having a low educational level and living in marginalized areas remain a constant in mexican women with cc among the sociodemographic factors associated with os are functional status age area of residence and ses since the clinical stage of the disease and treatment are the most decisive factors related to os prevention and detection programs with broader coverage are required to identify patients with cc in earlier stages to offer treatments that increase os abbreviations as

background in 2020 the highest incidence and mortality from cervical cancer cc were detected in low and middleincome countries cc remains a health problem for women living in them in mexico cc ranks second in cancer incidence and mortality in women the main characteristics of this population are low income low educational level and inadequate medical coverage the present study characterized the mexican population by cc and the sociodemographic variables that impacted overall survival os were identified methods a retrospective study that included a cohort of patients with a confirmed diagnosis of cc at the instituto nacional de cancerologia between 2003 and 2016 information was collected on sociodemographic variables related to the disease and osfour thousand six hundred thirtyone patients were included the median age was 51 years 785 were unemployed 444 lived in a ruralsuburban area 508 had a partner when collecting this information and 743 were classified as having low socioeconomic status age living in a ruralsuburban area more advanced stages of the disease and not receiving cancer treatment were associated with lower os conclusion cc continues to affect mainly women with minimal resources low educational levels and living in marginalized areas these characteristics influence the os prevention and timely detection programs education and training focused on this population and with broader coverage are required to identify patients with cc at earlier stages

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introduction executive function comprises a set of cognitive mechanisms necessary for holding information in ones mind and manipulating it controlling ones attention to override external lures and flexibly switching between tasks executive function is a set of foundational skills that are necessary for successful academic behavioral and socioemotional development as caregivers mothers are influential in the development of childrens executive functioning skills deaterdeckard further contends that the intergenerational transmission of executive function from parent to child can be altered by contextual features of the home environment for example the disorderly environment of chaotic households undermines the practice of executive function in mothers which is likely to result in poor executive function in adolescents moreover for families with lower socioeconomic status the overlap of cognitive aptitude in parentchild dyads is more sensitive to environmental factors we extend this research on the overlap of cognitive aptitude in lowincome families as moderated by environmental factors to the intergenerational transmission of executive function in motheradolescent dyads among lowincome mexican immigrant families as a group lowincome mexican children of immigrants are more likely to have lesseducated parents live in poverty and lag behind their peers on school outcomes mexican immigrant families also experience foreigner stress which is the belief that others perceive them as foreigners due to factors such as their ethnic minority status appearance or having an accent while speaking english collectively then mexican immigrants in the us may be a cultural group particularly vulnerable to both economic and foreigner stress there is evidence to suggest that culturally relevant stressors can undermine cognitive abilities such as executive function we propose to test how culturally relevant stressors in the environment influence the intergenerational transmission of executive function between mothers and adolescents in mexican immigrant families our focus is due to the paucity of research on executive function in adolescence specifically and limited research on this topic as it pertains to adolescents from lowincome and ethnic minority backgrounds adolescence is a developmental period that is susceptible to the effects of stress and executive function continues to develop throughout adolescence and into young adulthood to address this gap in knowledge our study examines the development of executive function components through motheradolescent intergenerational transmission and examines how perceived economic stress and perceived foreigner stress may influence adolescent executive function and may also moderate the intergenerational transmission of executive function intergenerational transmission of executive function intergenerational transmission of executive function refers to the familial transmission of executive function from parent to child which is manifested in the correlation between parent and child executive function such intergenerational transmission has been documented as a potential source of individual variability in childrens executive function and the effect of intergenerational transmission of executive function persists into adolescence indeed jester et al found that mothers executive function was positively associated with their adolescent childrens executive function even after accounting for parental and child iq parents influence their childrens executive function not only by the intergenerational transmission of genes but also through the home environment in which their children are reared for example parents can set household rules as a way for adolescents to practice inhibitory skills and adolescents practice their memory and attention skills while communicating with parents moreover given that mothers are often the primary caregivers adolescents may spend more time with their mothers the frequency of motheradolescent interactions within the shared family environment may enable the intergenerational transmission of executive function from mother to adolescent to understand individual variability in adolescent executive function then it is important to consider the factors in the rearing environment which may affect adolescents executive function and the strength of intergenerational transmission of executive function from mother to child in the current study we focused on three specific executive functions inhibitory control working memory and shifting ability lower inhibitory control is associated with higher likelihood of engaging in risky behaviors meanwhile as adolescents are surrounded with distractions like media and online games enhanced shifting ability may help them shift attention from external lures to academic tasks and better working memory may enable them to store and manipulate information needed for academic work in fact previous studies have found that the ability to shift attention and possessing strong working memory are key executive function skills for academic success among adolescents hence understanding factors that are associated with heterogeneity in executive function is important given that adolescence is a period with increased incidence of risktaking behaviors and academic outcomes during this period predict longterm adult outcomes environmental stressors and different types of executive function environmental stressors create differential opportunities for specific types of executive function to be more or less adaptive for example in highly stressful environments inhibitory skills are undermined while shifting abilities are enhanced suggesting that some types of executive function are adaptive when faced with high levels of environmental stressors specifically according to the adaptationbased approach to resilience living in a chaotic household a source of environmental stress amplifies shifting skills due to the need to detect threats and shortlived opportunities in an unpredictable environment at the same time a chaotic household may diminish inhibitory control due to a distracting environment diverting an individuals attention making it more difficult to suppress temptations for external stimuli additionally exposure to environmental stress disrupts working memory by impeding the ability to hold information in the short term in ones mind overall specific executive function may be strengthened or undermined by an environmental stressor in terms of whether the executive function is adaptive in the context of the stressor environmental stressors and intergenerational transmission of executive function based on the premise of the transactional model of cognitive development for children from families with enriched environments heritability accounts for most of the variance in intergenerational transmission of cognitive aptitude with environmental factors showing a minimal influence in contrast in lower socioeconomic status families the intergenerational transmission of cognitive ability is demonstrated through a stronger influence of the environment repressing the genetic effect this suggests that studies on lowses families need to take into consideration the potential role of environmental stressors in explicating the intergenerational transmission of parentchild executive function abilities in fact brieant et al demonstrated that household chaos which is characteristic of lowincome families may increase intergenerational transmission of preexisting executive function ability from mother to child based on brieant et al s study then in lowincome families childrens executive function may resemble that of parents because environmental stressors are salient in this context shaping how family members practice their executive function however the intergenerational transmission of executive function may not be uniform across different components of executive function one important factor yet to explore is whether specific executive function components may be differentially transmitted across generations andor influenced by different environmental stressors we expect the intergenerational transmission of each type of executive function to be distinct depending on whether the specific executive function that is practiced is adaptive in a given environment for example when mothers encounter environmental stressors the intergenerational transmission of working memory and inhibitory control may be undermined given the obstacles to practicing working memory and inhibitory control abilities in the highstress context on the other hand as enhanced shifting ability is adaptive in highstress contexts as it aids in adjusting to changing and uncertain environment the intergenerational transmission of shifting may be enhanced when mothers face environmental stressors we explore our research questions using a sample of adolescents given the emergence of distinct executive function components becoming more pronounced during adolescence than they were earlier in childhood this is likely due to lengthy maturation periods in brain structures that aid executive function such as the prefrontal cortex which matures in adolescence and early adulthood we focus on mexican immigrant families because the only study on how familial stress may influence executive function transmission was based on mostly european american families and did not examine how each component of executive function transmits intergenerationally from mother to child therefore it remains unclear how stressors more relevant to culturally distinct groups such as mexican immigrant families operate in motheradolescent intergenerational transmission of executive function economic stress as a culturally relevant stressor in mexican immigrant families mexican immigrant families in the us often experience high rates of poverty and economic stress may be a particularly relevant environmental factor for this group in fact children from disadvantaged socioeconomic backgrounds often perform worse on executive function measures and a metaanalysis revealed a small to moderate effect size between socioeconomic status and child executive function based on the family stress model economic stressfrom being unable to pay necessary expenses having inadequate material means or experiencing financial straincan indirectly result in negative developmental outcomes for children due to effects on parental behavior and parenting strategies indeed in lowincome mexican immigrant families parents subjective experience of economic hardship is a proximal predictor of family process and child developmental outcomes given this premise we focus on mothers perceived economic stress as a culturally relevant factor that may be associated with and or moderate the intergenerational transmission of executive function even after accounting for mothers socioeconomic status foreigner stress as a culturally relevant stressor in mexican immigrant families in addition to economic stress immigrant and ethnic minority families often experience stressors related to their daily experiences as minorities although latinos may identify themselves as americans much like their european american counterparts a growing body of research has found that they are often viewed as less american due to their physical appearance and ethnic minority background or because they speak english with an accent according to the racial position model foreigner stressa cultural stereotype in which ethnic minorities are seen as foreigners is a more salient and distinct stressor for latinos compared to other ethnic minority groups mothers with more perceived foreigner stress may feel alienated in their environment which may lead to a decrease in motivation andor lessen their ability to recruit cognitive resources when interacting with their children no study thus far has examined the potential moderating role of mothers foreigner stress on adolescents cognitive development however studies have shown that discriminatory experiences represent a salient stressor that may influence how one performs on executive function tasks if so foreigner stress as a form of discrimination may need to be considered in testing the intergenerational transmission of parentchild executive function our goal is to examine whether mothers foreigner stress is a moderator operating in the intergenerational transmission of mexicanorigin mothers executive function to their adolescents we hypothesize that mothers perceived foreigner stress as a culturally relevant stressor will moderate the motheradolescent transmission of executive function in mexican immigrant families the potential moderating effect of maternal foreigner stress is particularly important to explore given that economic stress is a wellstudied ecological stressor related to cognitive development but less is known about other culturallyrelevant stressors beyond the impact of lower ses and how they operate in immigrant and ethnic minority families the current study the current study examined motheradolescent intergenerational transmission of executive function and potential culturally relevant stressors that may moderate these processes among lowincome immigrant mexican familiesa highrisk group that has not been the focus of study in the executive function literature the first goal is to examine the strength of intergenerational transmission of different executive function components in motheradolescent dyads from mexican immigrant families our second goal is to examine whether mothers perceived economic stress and foreigner stress have a direct effect on adolescents executive function components our third goal is to examine whether mothers perceived environmental stressors especially economic stress and foreigner stress moderate the intergenerational transmission of executive function specifically we examine whether motheradolescent executive function transmission may be strengthened in environments in which mothers perceived economic stress and foreigner stress are at low levels reflecting the idea that low stress is more conducive to the intergenerational transmission of cognitive aptitude from parents to children no specific hypothesis was made about whether mothers perceived economic stress and foreigner stress would differentially impact the intergenerational transmission of different executive function components due to insufficient evidence to make strong predictions born while the rest were mexicoborn the median and mode of mothers education level was middle school or junior high school the median and mean household family income for participants was in the range of 30001 to 40000 methods materials backward digit span this task measures individuals working memory and materials from the wechsler scale were modified for computerbased presentation participants were presented with sets of digit lists on the computer screen and were instructed to remember the previously presented digits then type the digits in the reverse order of presentation for example if a participant were presented with the digits 829 then the participant would need to type in 928 trials began with a fixation cross presented in the middle of the computer screen for 3000 ms digit span trials were presented on the screen for 1000 ms times the number of digits in the list digit span was calculated by taking the score of the last digit list item for which the participant answered four out of the six trials correctly if the participant failed to meet this criterion at a given length the score from the previous digit span length was used participants who did not complete the threedigit practice trials successfully did not receive a score for digit span although some research suggests an accuracy cutoff of answering five out of the six trials correctly using this cutoff resulted in a large number of missing cases in the current lowincome immigrant sample we therefore decided to use the fouroutofsix cutoff criterion to retain at least 70 of the data higher scores in the backward digit span task indicate better working memory simon task the simon task measures inhibitory control via stimulusresponse reactions each participant completed 32 trials in a randomized order each trial began with an 800ms fixation cross at the screen center followed by a 250ms blank interval then a stimulus appeared on the left or right side of the screen for 1000 ms or until a response was made followed by another 250ms blank interval participants were instructed to press the keys on the keyboard that corresponded to the colors presented on the screen as quickly and as accurately as possible using their index fingers for congruent trials the redblue squares were presented to the same side as the corresponding keyboard key for incongruent trials the stimuli were presented on the opposite side of the corresponding keyboard key colorshape task the colorshape task measures cognitive shifting via stimulusresponse reactions a total of 48 trials were randomized and presented to participants in the same order at the beginning of each trial the target word color or shape appeared first on the screen for 200 ms in black at the top of the white screen next an image of a triangle or circle appeared with the same target word on the top of the screen the stimulus word and image remained on the screen until the participant selected a response key a 600ms blank slide was presented between trials using their index fingers participants categorized the images according to the given target word as quickly and as accurately as possible by pressing keys on the keyboard for a stay trial the given categorization word was consistent with the previous trial for a switch trial the given categorization word was different from the previous trial for both the simon and colorshape tasks response accuracy and reaction time in milliseconds were recorded for both adolescents and mothers the accuracy of the congruent trials in the simon task were almost at ceiling as was the accuracy of the stay trials in the colorshape task therefore we elected to use only the reaction time as the indicator of performance for both tasks the simon effect was calculated for each participant by subtracting their mean reaction time for congruent trials from their mean reaction time for incongruent trials with shorter time indicating better inhibitory control the switch cost was calculated for each participant by subtracting their mean reaction time for stay trials from their mean reaction time for switch trials with shorter time denoting better shifting measures mother foreigner stress foreigner stress was assessed using a fouritem scale validated among mexicanorigin adolescents mothers rated each item on a 5point scale ranging from 1 strongly disagree to 5 strongly agree scores were averaged across the four items so that higher scores indicate greater foreigner stress economic stress economic stress was measured with nine dichotomized items adapted from conger et al mothers reported whether or not the family experienced any of the specified situations because of financial needs answers were averaged across the nine items so that higher mean scores indicate greater economic stress covariates studies have found evidence that age gender immigrant status and language proficiency have an influence on individuals executive function for example executive control undergoes a maturation process during the course of adolescence and demonstrates different kinds of gender differences depending on the specific task adolescents of later immigrant generations have demonstrated better shifting ability and bilingualism can undermine as well as benefit an individuals executive control therefore we included adolescents selfreported age gender nativity and spanish and english proficiency as covariates in our study specifically adolescents proficiency in reading writing speaking and understanding spanish and english was assessed using a fivepoint scale validated for use with mexicanorigin adolescents ranging from 1 not well to 5 extremely well past studies have found that selfreport measures of language proficiency are correlated with objective measures of language proficiency we also controlled for mothers highest education level which was found to be positively correlated with child cognitive functioning mothers highest education level was assessed on a 11point scale ranging from 1 no formal schooling to 11 finished graduate degree procedure participants were tested individually during a home visit using laptops brought by research assistants all executive function tasks were presented on a laptop using the software package eprime 20 participants first completed the backward digit span followed by the simon task and colorshape task for the simon task and colorshape task participants completed four practice trials prior to the experimental trials after completing the executive function tasks participants completed online questionnaires about their language background and experiences all materials were prepared in both english and spanish the questionnaires were originally designed in english a team of bilingual and bicultural research assistants first translated the materials to spanish and then backtranslated them to english participants chose which language they preferred to use for the interview and cognitive tasks families were compensated 60 for participating in the study analytical strategy missing data rates ranged from 0 to 1 for all variables collected via survey indicators of executive function had missing rates ranging from 0 to 25 littles test of missing completely at random was conducted in spss demonstrating that any missing data was completely at random 6186 p 048 the following path analyses were conducted in mplus 73 using maximum likelihood estimation with robust standard errors to test the studys questions for each participant in the simon task or the colorshape task trials with reaction times outside three standard deviations from each persons mean for each condition were excluded from analysis as shown in the conceptual model a set of baseline models linking mothers executive function to adolescents executive function were tested for each executive function separately we then tested a set of main effect models where the main effects of mothers foreigner stress and mothers economic stress to adolescents executive function were added to the baseline model building upon the main effect models two moderation paths were added to examine whether mothers perceived foreigner stress and economic stress moderated the intergenerational transmission of executive function missing data were handled using full information maximum likelihood covariates included mothers highest education level adolescents age gender nativity spanish proficiency and english proficiency effects of covariates on all study variables were controlled in the model table 1 presents descriptive information on the studys variables and demographics additional file 1 figures s1 to s3 are violin plots showing the distribution of adolescents and mothers performances on each executive function task results path model results the baseline models with covariates were saturated models as shown in table 2 only the working memory model showed that mothers digit span was positively associated with adolescents digit span with a significant rsquare in explaining the variability in adolescent digit span all main effect models had adequate model fit specifically the working memory model revealed a significant positive main effect of mothers digit span on adolescents digit span while no direct effects of economic stress or foreigner stress on adolescents digit span were found for the switch cost model no significant main effect of any predictor on adolescents switch cost reaction time was found for the inhibitory control model there was a positive main effect of mothers economic stress on adolescents simon effect indicating that higher economic stress was associated with worse inhibitory control the moderation models fit the data well across the three executive function components in the working memory model the positive main effect of mothers digit span remained significant after adding the two moderating paths there was also a significant interaction effect of mothers digit span and mothers foreigner stress on adolescents digit span while no main effect of adolescents switch cost was observed the model for shifting ability revealed a significant interaction term between switch cost reaction time and mothers foreigner stress to adolescents switch cost rt in addition similar to the main effect model the moderation model for inhibitory control revealed a significant direct positive effect of mothers economic stress on adolescents simon effect neither foreigner stress nor economic stress showed a significant moderating effect in the inhibitory control model in addition it is also worth noting that maternal education level as an indicator of socioeconomic status did not have a significant positive effect on adolescents executive function across the three models simple slope analyses simple slope analyses were performed to probe the two significant interactions at the mean level one standard deviation below the mean and one standard deviation above the mean for each moderator for the interaction of mothers digit span and mothers foreigner stress with adolescents digit span the analysis showed that a larger maternal digit span was significantly related to larger adolescent digit span only when mothers reported low levels or mean levels of foreigner stress but not high levels of foreigner stress probing the switch cost rt × mothers foreigner stress interaction showed that mothers rt in switch cost was positively associated with adolescents rt in switch cost only when mothers reported high levels of foreigner stress but not mean or low levels discussion the link from parent executive function to child executive function has been demonstrated mainly in early childhood more recently studies have found that the intergenerational transmission of executive function could persist into early adolescence our study extends previous findings by observing intergenerational transmission of executive function components in late adolescence suggesting that executive function development in late adolescence may still be affected by familial influences in mexican immigrant families intergenerational transmission was the most salient for working memory among the three executive functions assessed we also found distinct patterns of influence for different executive function abilities in the context of maternal stressors these stressors were related to adolescents executive function either by altering the intergenerational transmission process or directly influencing adolescent executive function depending on the type of executive function specifically we found that low foreigner stress was related to stronger associations between mothers and adolescents working memory in contrast more adverse contexts related to strengthened intergenerational transmission of shifting ability instead of moderating the intergenerational transmission of executive function higher maternal economic stress was directly associated with worse adolescent inhibitory control while it has been shown that the development of executive function could continue into young adulthood little is known about the familial factors that may influence the development of executive function in late adolescence the current study is one of the first to demonstrate that maternal executive function may still contribute to adolescents executive function particularly working memory in late adolescence we found that intergenerational transmission could explain a fair amount of variation in adolescents working memory even after controlling for factors such as adolescents age and mothers education however our study found no evidence for a main effect in the intergenerational transmission of inhibitory control or shifting in the baseline models the significant maternal influence on adolescent working memory but not the other two cognitive functions may be attributed to the fundamental role of working memory in a variety of higherorder cognitive tasks such as language comprehension reasoning learning and ability to maintain and pursue goals which are all common in peoples daytoday interactions as parents executive function can be transmitted to their children via parentchild interactions being engaged in a common cognitive task during daily parentchild interactions may mean the intergenerational transmission of maternal working memory is particularly strong as there is insufficient evidence in the current study to draw definitive conclusions we encourage future researchers to undertake a deeper examination of the reason why certain types of executive function are more likely to be transmitted from parent to child as posited by prior research the development of adolescent executive function involves transactional processes whereby parent executive function works in conjunction with environmental factors to shape adolescent executive function the intergenerational transmission of executive function is particularly vulnerable to environmental influences in less advantaged socioeconomic contexts the current findings suggest that maternal foreigner stress may be one salient environmental factor that modifies the intergenerational transmission of executive function among motherchild dyads from lowincome mexican immigrant families the intergenerational transmission of working memory and shifting can both be altered by the foreigner stress perceived by mothers yet in different ways underscoring the importance of examining each executive function component on its own rather than considering executive function as a singular construct the intergenerational link for working memory was augmented when mothers reported low to mean levels of foreigner stress the intergenerational transmission of shifting on the other hand emerged only when mothers perceived high levels of foreigner stress this finding is consistent with past literature that identified the various types of executive fig 2 a mothers working memory relating to adolescents working memory at low mean and high levels of maternal foreigner stress b mothers shifting ability relating to adolescents shifting ability at varying levels of maternal foreigner stress the numbers in parentheses indicate unstandardized simple slopes and their pvalue function as separate factors especially during adolescence the distinct characteristics of each type of executive function may be key for the different moderating mechanisms we found for working memory transmission versus shifting transmission specifically working memory involves shortterm maintenance and manipulation of information the extant literature on working memory and stress has consistently demonstrated that individuals working memory would be undermined and even impaired by acute or chronic stress individual differences in the performance of working memory are likely to be attenuated in the presence of stress in fact a study based on laboratory experiments found that undergraduate students with high working memory adopted more sophisticated algorithms to solve math problems and had higher accuracy than those with low working memory only in lowstress contexts but not highstress contexts hence one possibility is that mothers with low foreigner stress may be better positioned to fully utilize their working memory in their daytoday activities such that their working memory may be more likely to be transmitted to their children thus there was a stronger positive link between mothers working memory and that of their children when mothers perceived low foreigner stress a second type of executive function examined in the study shifting is a core component of cognitive flexibility it is the ability to flexibly switch between behaviors rules or mental states as shifting helps individuals adapt to their changing situations it may be that individual differences in shifting ability are more likely to manifest in contexts that require constant switching between rules or mindsets although no study has directly examined this speculation one relevant study found that the shifting advantage of living in an unpredictable childhood environment only emerged for undergraduate participants who had a sense of environmental uncertainty we surmise that mexican immigrant mothers with higher foreigner stress are likely to face or perceive more challenges involving switching between languages and cultural rules thereby using their shifting skills more often for example a mother may need to make sense of a notice written by her landlord in english rather than spanish while also shifting attention to parenting her usborn adolescents who possess stronger american cultural values relative to her stronger mexican cultural values with more exposure to mothers utilization of shifting ability it is plausible that adolescents would resemble their mothers in terms of shifting ability as such it is likely that the intergenerational transmission of shifting was enhanced when mothers experienced higher levels of foreigner stress more studies are needed to investigate this hypothesis in summary we argue that an executive function skill tends to be transmitted from mothers to adolescents when the environment facilitates the emergence of individual differences in that specific executive function for mothers while low maternal foreigner stress may allow mothers to fully apply their working memory resources high maternal foreigner stress may create more opportunities for mothers to utilize their shifting ability therefore the intergenerational transmission of working memory was enhanced when mothers reported lower foreigner stress whereas the intergenerational transmission of shifting was strengthened when mothers reported higher foreigner stress the impact of foreigner stress on immigrant families may be more pronounced in the years to come given the current sociocultural climate and the rise of antiimmigrant sentiment in the us future research on the intergenerational transmission of executive function among ethnic minority populations should also consider factors that are culturally relevant such as foreigner stress interestingly unlike maternal foreigner stress maternal economic stress did not demonstrate any moderating effect upon the intergenerational transmission of executive function we assume that one possible reason for this finding is that the familys financial responsibilities are typically assumed by the father rather than the mother in traditional mexican culture although the mothers who participated in the current study experienced economic stress the burden of resolving the financial difficulties behind it may have fallen more upon fathers therefore mothers economic stress may have interfered less with the transmission of executive function from mothers to adolescents it should also be noted that the current study is based on a lowincome sample the moderating effect of economic stress may manifest when there is more variation in participants family income rather than moderating the intergenerational transmission of executive function mothers economic stress compromised the development of adolescents inhibitory control directly this is consistent with past research which found that children from less advantaged socioeconomic backgrounds tend to develop poorer executive function to some extent maternal economic stress could reflect the familys financial condition and social welfare mothers who perceived more economic stress may have experienced greater difficulty providing their adolescents with the rich stable and stimulating environment necessary for optimal cognitive development lacking such an environment may be particularly harmful to the development of inhibitory control inhibitory control is adaptive in the pursuit of longterm goals as it involves the ability to intentionally suppress dominant responses families with stronger economic stress may not have consistent instrumental support for the children consequently less inhibition may be an adaptive strategy that allows children to take advantage of fleeting opportunities and rewards in the short term limitations the current study has several limitations that may compromise the generalizability of its findings firstly it is important to note that the effects are essentially correlational as the analyses were based on concurrent data it is unclear whether the concurrent associations would unfold across time in a similar way therefore caution should be taken in making predictions based on the current findings future research should examine these associations using longitudinal data secondly while our study has controlled for language proficiency and maternal education as a proxy for intelligence we did not assess general intelligence although there is evidence that the intergenerational transmission of executive function is independent of both parent intelligence and adolescent intelligence it is still important to rule out possible confounding effects of intelligence in order to be more confident about the specific effects of executive function third although executive function in our study was measured by welldeveloped paradigms in experimental settings future studies are needed to understand the ecological validity of our paradigms in predicting adolescents everyday executive function skills relatedly future studies that incorporate multiple informants of adolescents executive function andor adopt paradigms that can be applied in a naturalistic setting are needed to understand the ecological validity of our findings finally although the current study considers the role of economic stress and foreigner stress in the development of adolescent executive functions among mexican immigrant families other environmental factors are also worth noting and investigating factors related to immigrant status physical appearance and language barriers are likely to matter to individuals with a mexican immigrant background we encourage future research to explore the development of adolescent executive function in contexts that are salient to the target population for example research focusing on immigrant adolescents may consider reception and immigration policies which are increasingly salient cultural contexts for immigrants in addition given the heavily gendered family roles assumed by mothers and fathers in traditional mexican culture it is likely that the intergenerational transmission of executive function operates differently for motherchild dyads versus fatherchild dyads also the current sample was limited in terms of participants socioeconomic background as the impact of environmental factors on executive functions intergenerational transmission is likely to be stronger for lowses families the associations found in the current study may not be found for families with higher ses moreover our research on environmental factors that are culturally relevant for mexican americans such as foreigner stress was not tested for other cultural groups which would have provided a useful contrast to the current findings on intergenerational transmission of executive function future studies should include participants with more diverse ethnic and socioeconomic backgrounds for a more comprehensive understanding of the intergenerational transmission of executive function conclusion our findings offer three major contributions to the existing literature first our study extends prior research which has mainly focused on early childhood and data from middleclass white samples by demonstrating the intergenerational transmission of executive function during late adolescence in a sample of lowincome mexican immigrant families the intergenerational transmission of working memory could be particularly pronounced for the target population of the present study possibly because working memory has greater vulnerability to the home environment shared by the motheradolescent dyad second our study suggests that the development of adolescent executive function may be affected differently by maternal foreigner stress and economic stress in moderating the intergenerational transmission of executive function stressors that are more specific to ethnic minority groups such as foreigner stress may be more powerful than economic stress considering the current antiimmigrant sentiment in the us these findings underscore the importance of studying culturallyspecific factors in immigrant populations finally our findings indicate that the process of intergenerational transmission in the context of culturally relevant stress experienced by mothers operates differently according to the component of executive function being examined which suggests that executive function should be examined as a multidimensional construct rather than a unidimensional one funding competing interests the authors declare that they have no competing interests

the intergenerational transmission of executive function may be enhanced or interrupted by culturally salient environmental stressors that shape the practice of executive function in the family building upon past research the current study tests whether culturally relevant stressors such as economic stress and foreigner stress have a direct effect on adolescent executive function as well as whether they modify the intergenerational transmission of motherchild executive function ie working memory inhibitory control and shifting in lowincome mexican immigrant families the sample consists of 179 mexican american adolescents m age 1703 years sd age 083 58 females and their mexicoborn mothers m age 4325 years sd age 590 results show that mothers perceived economic stress is associated with poor inhibitory control in adolescents low levels of mothers perceived foreigner stress related to a stronger association between mothers and adolescents working memory while high levels of mothers perceived foreigner stress related to enhanced intergenerational transmission of poor shifting ability study findings demonstrate the prominence of perceived foreigner stress as a contextually relevant factor moderating the intergenerational transmission of motherchild executive function in lowincome mexican immigrant families

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background in many countries smoking remains the leading preventable cause of death in north america reductions in smoking rates are stabilising and in recent years those involved in tobacco control programming have turned their attention to particular segments of society that are at greatest risk for tobacco use especially people with mental illness an appreciation of the high rate of tobacco use by those with mental illness is emerging in a usa populationbased study of 4441 respondents aged 1554 years lasser and colleagues 1 reported that current smoking rates for those with no mental illness lifetime mental illness or mental illness in the past month were 225 348 and 410 respectively the burden of tobacco use appears to be disproportionally borne by those with mental illness dani and harris reported that 7 of americans have a mental illness and that this relatively small group consumes 34 of all cigarettes sold in the usa 2 those with mental illness are noted to have a higher all cause mortality rate compared with the general population although suicide and accidents contribute to the high rate very high mortality rates due to cardiovascular disease are apparent 3 those with serious mental illness are at particular risk for tobacco use previous studies have found very high smoking rates among selected populations of people with smi including psychiatric outpatients 4 patients in state mental hospitals in the usa and patients in several other countries 56 there is some evidence that smoking rates vary by psychiatric diagnosis with individuals with a diagnosis of schizophrenia having the highest tobacco use rate 7 sex and gender differences in tobacco use have been the focus of numerous studies it is increasingly recognised that men and women differ in relation to their reasons for smoking levels of addiction to nicotine and difficulties with cessation some of these differences may be attributed to social factors while others may be attributable to biological factors 8 these sex and gender differences have not been fully explored in psychiatric populations although it is now recognised that substance use disorders are prevalent among people with smi tobacco use is often not included in substance use screening 9 even though there are emerging links being made between tobacco use and other substance use and in some instances with antipsychotic medication use 10 there is limited understanding of whether those with smi who use tobacco are also more likely to use other substances and if so which substances are most frequently used a picture of tobacco use patterns among those with smi is emerging however there are several unanswered questions in particular much of the data collected have been limited to particular clinics or inpatient groups and few researchers have disaggregated their data by gender given recent trends of deinstitutionalisation further study is warranted of tobacco use patterns among men and women living in the community with smi there also is a need to explore how tobacco use varies by diagnosis whether it differs by symptomatology and other substance use and whether socialenvironmental factors are salient the purpose of this study was to determine the rate of tobacco use among people with smi accessing communitybased mental health services and to learn more about the factors associated with their tobacco use the specific objectives of the research were to describe the profile of tobacco use among people with smi determine whether tobacco use differs by psychiatric diagnosis and by gender and determine the extent to which comorbid substance use and socialenvironmental factors are associated with smoking status methods we conducted a crosssectional survey in which we targeted all adults with smi who received services from communitybased mental health teams in vancouver canada the vast majority of noninstitutionalised persons with a diagnosis of smi in this city are followed by one of these teams each mental health team provides psychiatric assessment and comprehensive treatment through dropin and outreach services for people in their catchment area services include medication management individual and group therapy rehabilitation and education many clients receive additional support in the form of rehabilitation programming or housing through contracted agencies sample we sought to obtain a representative sample of people with smi receiving community mental health services because of confidentiality concerns however we were not permitted to draw a random sample from the population of people receiving services consequently we recruited voluntary participants who were receiving services from seven of the eight mental health teams eligible participants were individuals whose health records were flagged as active and who received care from an adult care program all study participants were living in the community and were able to communicate and be understood in english mandarin cantonese or punjabi procedures the research staff visited each community mental health team provided information about the study answered questions and negotiated strategies to access eligible participants a research assistant recruited participants at the mental health team offices during regular operating hours the participants were introduced to the survey either through the reception desk personnel or their case managers the participants could self refer to the research staff in response to brochures and flyers available in the office waiting areas the research staff explained the study in detail obtained written fully informed consent and administered the questionnaire 11 upon completion of the questionnaire the participants received a 10 gift certificate for a local grocery store data collection occurred between october 2005 and october 2006 with each mental health team involved for approximately 46 months ethical approval ethical approval was obtained from the behavioural research ethics board of the university of british columbia approval to conduct the research was obtained from vancouver coastal health vancouver community health service delivery area measures the questionnaire which included several scales and items requiring 2045 minutes to complete was administered by the research staff demographics the demographic items included age gender and ethniccultural background the information from this item was used to create a racialised group variable the use of this term is meant to construe the belief that racial classifications are socially constructed and embedded in eurocentric notions of inferiority colonization and prestige 12 in the study community people who are aboriginal asian south asian or black tend to be racialised which has implications for their health 13 the other demographic variables included marital status current living situation group home or other and housing type financial support disposable income and income prioritizing strategies psychiatric diagnosis not all of the participants provided permission to access their medical records these individuals diagnostic information was limited to a selfreport of the psychiatric diagnosis for the remainder who provided consent information about their diagnoses was collected from their existing mental health team medical record once referred to a community mental health team all clients are assessed by one of the teams psychiatrists the psychiatrists typically base their diagnoses on findings of a onehour assessment interview dsm iv criteria are used to guide the diagnostic process a diagnosis is recorded at the time of the clients intake to community mental health services and then modified as required for the purposes of this study the most current diagnosis was recorded for the purpose of the analysis we classified the specific diagnoses as schizophrenia spectrum disorders mood disorders or anxiety disorders a diagnosis of a schizophrenia spectrum disorder included schizophrenia and its subtypes schizoaffective disorder delusional disorder or psychosis not otherwise specified mood disorders included diagnoses of bipolar disorder major depression manic depression or dysthymia anxiety disorders included diagnoses of obsessive compulsive disorder generalized anxiety disorder and panic disorder psychiatric symptoms psychiatric symptoms were assessed with the brief symptom inventory 14 which has been validated for use with people living with schizophrenia and is preferred over other scales of psychopathology because it is relatively noninvasive quick to administer and suitable for use by research staff 15 the 18item scale measures anxiety depression and general somatic symptoms using a 5point scale to measure the extent of distress experienced over the past week the response options were not at all a little bit moderately quite a bit and extremely the internal consistency for the global severity index has been reported to be strong with a coefficient alpha of 89 15 in this study the scale had a coefficient alpha of 92 we followed the prescribed bsi scoring method the raw gsi score was calculated by adding the 18 items 16 if participants had more than 2 item responses missing for any subscale their scores were not calculated and the case was treated as missing when participants had 1 or 2 missing items values were imputed by rounding the mean of the completed items to the nearest whole number the gsi scores were standardized using t scores with a mean of 50 and an sd of 10 to determine caseness those with gsi scores of 63 or greater were deemed to be at positive risk for psychological distress 1416 tobacco use patterns smoking status was determined by asking the participants if they had ever smoked whether they had smoked more than 100 cigarettes in their lifetime when they smoked their last cigarette and if they smoked every day 17 the participants were classified as nonsmokers former smokers or current smokers a binary variable was created with current smoker versus formernever smoker the participants also were asked do you consider yourself a current smoker there was excellent agreement between the classification of smoking status based on the number of cigarettes smoked in the past 30 days and the participants selfreported smoking status tobacco use patterns and practices were measured by determining the amount of tobacco smoked each day the age of smoking initiation 18 and reasons for tobacco use 19 physical health consequences of tobacco use were assessed with the item do you have or have you had symptoms that you believe were caused or made worse by smoking 20 items also were included to determine the primary sources of tobacco procurement average weekly expenditure on tobacco and type of cigarettes smoked nicotine dependence was measured with the fagerström test for nicotine dependence 20 this test is appropriate for the assessment of nicotine dependence in smokers with schizophrenia 21 the coding algorithm yields a total score of 010 scores above 6 are indicative of a high level of dependence although widely used the internal consistency for the ftnd scale has been borderline 22 in this study the cronbachs alpha was 50 in addition to using this scale the participants were asked to rate their tobacco addiction using a selfrated addiction scale of 010 where 0 was not at all addicted and 10 was extremely addicted they also were asked about using tobacco to manage their psychiatric symptoms some people use smoking to cope with their symptoms such as having anxiety or hearing voices how often do you smoke to cope with symptoms the item was scored with a 4point scale rated as not at all a little somewhat or a great deal another openended question asked what symptoms do cigarettes help you manage substance use comorbid substance use was assessed with items from the substance use section of the addiction severity index originally developed for clinical purposes 23 24 the asi has seven sections measuring various aspects of an individuals life that may be affected by substance use for research purposes the use of individual items from the substance use section of the asi has been found to be reliable valid and valuable 25 the participants were asked how many days in the past month did you useany alcohol alcohol to get drunk heroin methadone opium codeine or pain killers like tylenol 3 sedatives hypnotics or tranquilizers like valium or xanax cocaine or crack amphetamines like speed e or meth marijuana hallucinogens like lsd or mushrooms inhalants like glue paint thinner or gas any other substances specify the asi results were reported as number of days and were categorized into no none or yes 1 or more days because of the participants infrequent regular use and the distributional properties of their responses 26 analysis a total of 788 people participated in the study which represents approximately 20 of the clients who received care from the 7 community mental health teams the data from these clients were cleaned and screened before analysis to ensure missing data were random in occurrence and that all data were within their excepted ranges responses from 59 individuals were excluded because they did not have a clear psychiatric diagnosis descriptive analysis of the sample employed chi square tests to determine the associations between psychiatric diagnosis and the categorical study variables independent sample ttests employing levines test for equality of variance were employed to examine the relationships between psychiatric diagnosis and the continuous variables we employed hosmer and lemeshows modelbuilding process to determine the variables that were associated with current smoking status 27 first we employed univariate logistic regression analyses to identify the study variables associated with smoking status and conducted these analyses for the entire sample and for men and women separately in the second step variables that were associated with smoking status at p ≤ 25 were included in the multivariate logistic regression models to obtain the most parsimonious and stable models we then trimmed them by removing statistically nonsignificant variables sequentially by examining the wald statistic and comparison of the likelihood ratios if the likelihood ratio test was significant when a nonsignificant variable was removed then the variable was added back to the model once the main effects models were finalized all possible interactions between diagnostic category and the other variables were examined all analyses were conducted with ibm spss statistics 18 results demographics about one half of the participants were women 266 were of a racialised group 765 had a high school or better education 630 reported being single and never married 710 lived in independent private houses or apartments 529 lived alone and the majority received government disability benefits the average age of the participants was 474 years to determine if those who provided access to their records differed from those who did not we compared the two groups by the variables listed in table 1 and found no statistically significant differences psychiatric diagnostic category the majority of the participants had a diagnosis of schizophrenia spectrum disorder and the remainder had mood or anxiety disorders for the subsequent analyses we combined those with a mood disorder or anxiety disorder into a single group the participants with schizophrenia spectrum disorder were more likely to be male single and never married live in a residential facility or group residential home and receive social assistance the mean bsi scores for the sample were somatisation 108 depression 120 and anxiety 118 in terms of caseness of psychological distress 122 of the participants surpassed the gsi cutoff value of 63 or greater in general those with mood or anxiety disorders had greater symptomatology 154 of this group compared with 100 of those with schizophrenia spectrum disorder met the caseness criterion tobacco use almost one half of the participants were current smokers 575 of the men and 356 of the women were current smokers the prevalence of participants who reported ever smoking was 893 most of the participants began smoking at 15 years of age or younger of those who currently smoked the average number of cigarettes smoked daily was 202 cigarettes and the main reasons reported for smoking were addiction and anxiety the majority of current smokers reported smoking every day had smoked for 30 years on average and were selfidentified chain smokers almost one third of the current smokers reported lighting a second cigarette while the first cigarette was still burning the current smokers median ftnd score was 60 in relation to their selfrated addiction the mean response was 74 on a scale of 0 to 10 although the selfrated addiction scores were not significantly associated with the ftnd scores they were associated with the average number of cigarettes smoked per day and age of smoking initiation about one half of the participants revealed that they had experienced symptoms of a disease or illness that were caused or worsened by their smoking almost all of the current smokers reported buying tobacco from a store which was the most common method of procuring tobacco although it was not exclusive to other methods including receiving tobacco from friends bumming cigarettes from people sharing someone elses and picking up butts the average amount of money spent per week on tobacco was 4050 almost one half of the current smokers indicated that they had on occasion given up buying food so that they would have enough tobacco many of the current smokers reported that they coped with their psychiatric symptoms by smoking and 303 reported doing this a great deal those who answered affirmatively indicated that cigarettes helped them manage multiple symptoms including anxiety stress depression and hearing voices delusions bivariate associations with current smoking status the men with a schizophrenia spectrum disorder in the sample were 18 times more likely to be current smokers than were those men with a mood or anxiety disorder the association between diagnostic category and smoking status was not significant for the women the gsi score was not statistically significantly associated with smoking the men were 25 times more likely to smoke than were the women for women being young was a risk factor for men the age group with the greatest risk of smoking was the 5059 years of age group being a member of racialised group was protective against smoking for the women only whiteeuropean women were 24 times more likely to smoke compared with racialised women education was only significant for the men those with less than high school education were about twice as likely to smoke compared with those who were better educated compared with those who were married men who were separated or divorced were 33 times more likely to smoke marital status and education were not risk factors for the women the respondents who reported having no housing or who lived in temporary shelters or hostels were very likely to smoke there were too few cases of people without housing to provide a breakdown by gender other forms of housing however also placed the women at risk of smoking specifically women in residential facilities were 27 times more likely to smoke than were women who lived independently similarly living with their family protected both men and women from smoking the only form of financial support received that was associated with smoking status was social assistance or welfare both men and women who received this form of support were thrice as likely to smoke compared with those not on assistance other substance use was associated with smoking status for men who used alcohol to intoxication in the previous month or who had used any cocaine or cannabis in the past month current tobacco smoking was also likely for women the only other substance use that was associated with their smoking status was cannabis use multivariate associations with current smoking status the multivariate genderspecific models revealed the following for the men the significant predictors of smoking status adjusted for confounding were having a schizophrenia spectrum disorder vs a mood or anxiety disorder having less than a high school education being separated or divorced rather than married receiving social assistance or welfare and having used cannabis in the past month being a member of a racialised group and having used cocaine in the past month had odds ratios that spanned unity retaining these variables in the model however improved the model the nagelkerke r 2 for this model with seven variables was 23 the correct classification rates were 638 for current smokers and 709 for nonsmokers the overall correct classification rate was 670 for the women the significant predictors of smoking status were age being white or of european origin living in a residential facility vs independent living receiving social assistance or welfare and having used cannabis in the past month the nagelkerke r 2 for this model with five variables was 17 the correct classification rates were 376 for current smokers and 869 for nonsmokers the overall correct classification rate was 695 discussion it is noteworthy that almost one half of the study participants were current smokers this is almost three times family contribution 08 05 12 09 04 19 10 06 16 any alcohol intoxication the 2007 smoking rate of 14 in the province of british columbia canada 28 the participants tended to be heavy smokers who were highly dependent on nicotine other researchers also have reported very high rates of tobacco dependence among people with serious mental illness 6 particularly those with schizophrenia 29 what is particularly troubling about our findings is that vancouver is a region that has some of the strongest tobacco control measures in canada 30 although these measures have been instrumental in reducing the smoking rate to one of the lowest in canada a more tailored approach with considerable support including pharmacological aid social support and other resources is needed for communitybased people with serious mental illness we found that tobacco use rates varied by psychiatric diagnosis and that diagnosis was only predictive of mens smoking the overall rate is lower than what has been reported elsewhere it has been reported that in kentucky the prevalence of current daily smoking for patients with bipolar disorder and schizophrenia were 66 and 74 respectively 31 this may point to the importance of the social context in influencing the tobacco use of people with serious mental illness kentucky a tobacco producing state in the usa is reported to have the highest current smoking prevalence rate in the usa 32 more men than women reported being current smokers and the predictors of tobacco use varied by gender in the genderstratified analysis we found differential predictors of current smoking status these findings suggest that while strategies need to be found for people with mental health issues in general services need to be gender sensitive gender has historically been a factor in tobacco use men have been more likely to smoke than have women although the gender gap in the general populations smoking rate is narrowing there remains a substantial differential in the smoking rates of men and women with serious mental illness more research is needed of people with serious mental illness to untangle the relationships among gender psychiatric diagnosis the social context and smoking status the specific needs of people with a diagnosis of schizophrenia spectrum disorder are unique for example they may require more support for cessation and they may need education about how their negative symptoms may interfere with some of the conventional methods of cessation support such as group interaction the finding that smokers had higher rates of substance use than did the nonsmokers echoes the results of other researchers and magnifies the overlap between tobacco use and other substance use best practice guidelines recommend that treatment for these cooccurring disorders be integrated 33 although movement towards the integration of mental health and addiction services is gaining momentum and more settings have begun to successfully incorporate smoking cessation into their practice 34 there is still much dispute among clinicians about whether tobacco use should be treated as an addiction and considered part of the spectrum of substance use within the context of dual disorder services many of the smokers in this study reported strategically using tobacco to cope with their psychiatric symptoms reports published elsewhere have discussed the complicated roles nicotine and tobacco play in the lives of people with mental illness 35 the stimulating effect of nicotine is known to modulate social and interpersonal factors to reduce anxiety and to relieve boredom nicotine also alters the neurochemistry of the brain and affects the rate at which psychotropic medications are metabolised 35 clearly the use of tobacco has serious implications for psychiatric recovery which is a compelling reason to advocate strongly for the clinical monitoring of changes in tobacco use in clients tobacco cessation support is a service that should be offered to all clients wanting to stop smoking and smoking cessation interventions have been shown to be effective in mentally ill clients residing in the community 36 the reason for the high smoking rates among persons with mental illness may in part be related to mental healthcare providers reluctance to integrate interventions for tobacco reduction into their practice and the lack of attention given to tobacco dependence in organizations providing services for the mentally ill integrated solutions must include preparing mental health providers to support tobacco reduction and smoking cessation efforts it is clear that the economic costs of tobacco use place a significant burden on people with serious mental illness especially because many rely on government subsistence which is well below the poverty line 37 at the time of this survey income from a disability pension was capped at 85642 per month social assistance for a single person with a disability provided by the government of bc was 62 of the lowincome cut off established by the federal government 38 smokers in this study spent an average of 160 per month on tobacco almost 20 of their monthly income in addition many of the smokers made choices to smoke butts and to buy cigarettes instead of food it is well documented that poverty is associated with poorer health outcomes and the extra burden of tobaccorelated effects confounds these peoples already compromised health outcomes tobacco use treatments have been shown to be highly costeffective 39 subsidizing nicotine replacement therapy is efficacious in significantly increasing cessation rates and the number of cessation attempts by smokers wanting to stop smoking 40 in heavy smokers higher doses of nrt have been shown to increase cessation rates 41 a way to reduce both the physical and the economic burden of tobacco is for governments or thirdparty health insurers to provide nicotine replacement therapeutic products free of charge for people with serious mental illness these findings must be considered in light of several methodological limitations first the relatively low participation rate limits our ability to generalize to the communitybased mental health population as a whole other communitybased studies of people with mental illness have reported similar response rates 4243 there are specific factors associated with seriously mentally ill peoples willingness to engage in research 4445 many of these factors affected our ability to recruit participants including the lack of a supportive research culture in the study settings and a reliance on mental health team staff for client referral clientspecific factors included a fear that the information provided would not be kept confidential and would have an impact on their healthcare the length of the questionnaire may have been a barrier many people believed that they could not complete a 45minute interview the presence of some symptoms may have had an additional impact on recruitment another limitation of the study relates to the accuracy of the medical diagnosis data 19 of the participants did not permit access to their medical records our reliance on selfreported diagnosis for these case may have resulted in misclassification bias additionally some confidence intervals for the odds ratios were very wide indicating a lack of precision in these estimates conclusion people with serious mental illness have very high rates of tobacco use and levels of nicotine dependence and bear a significant health and economic burden because of their tobacco use many of the factors that are associated with smoking vary by gender and socioenvironmental factors play a key role researchers have suggested that smoking particularly by those with schizophrenia is likely the result of selfmedication for symptoms consistent with srinivasan and tharas conclusions we found that social factors including where one lives and ones marital status education and sources of income are associated with smoking which suggests a more multifacted explanation of tobacco use in the presence of mental illness is required 46 the finding that gender is strongly associated with smoking status may be explained by a biological sexbased factor or it may represent further support for the hypothesis that social determinants are significant factors at play more work must be undertaken to better understand the motivators and reinforcers of tobacco use in this population and to develop appropriate tobacco cessation interventions authors contributions jlj was the principal investigator for the study and wrote the major sections of the paper par completed the final data analysis and wrote several components of the paper lam assisted with data collection and preliminary analysis and contributed to writing the findings section ctco conducted some data analysis rmp assisted with planning the study and commented on the paper jlb contributed to the development of the project and offered comments on the paper mg aided in designing the recruitment strategy and offered comments on the paper as and mo were members of the research team and offered comments on the paper all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background in many countries smoking remains the leading preventable cause of death in north america reductions in population smoking levels are stabilising and in recent years those involved in tobacco control programming have turned their attention to particular segments of society that are at greatest risk for tobacco use one such group is people with mental illness a picture of tobacco use patterns among those with mental illness is beginning to emerge however there are several unanswered questions in particular most studies have been limited to particular inpatient groups in addition while it is recognised that men and women differ in relation to their reasons for smoking levels of addiction to nicotine and difficulties with cessation these sex and gender differences have not been fully explored in psychiatric populations methods community residents with serious mental illness were surveyed to describe their patterns of tobacco use and to develop a genderspecific profile of their smoking status and its predictors results of 729 respondents almost one half 468 were current tobacco users with high nicotine dependence levels they spent a majority of their income on tobacco and reported using smoking to cope with their psychiatric symptoms current smokers compared with nonsmokers were more likely to be diagnosed with a schizophrenia spectrum disorder rather than a mood disorder male relatively young not a member of a racialised group eg aboriginal asian south asian black poorly educated separated or divorced housed in a residential facility shelter or on the street receiving social assistance and reporting comorbid substance use there is evidence of a gender interaction with these factors in the genderspecific multivariate logistic regression models schizophrenia spectrum disorder versus mood disorder was not predictive of womens smoking nor was education marital status or cocaine use women and not men however were more likely to be smokers if they were young and living in a residential facilityfor men only the presence of schizophrenia spectrum disorder is a risk factor for tobacco use other factors of a social nature contribute to the risk of smoking for both men and women with serious mental illness the findings suggest that important social determinants of smoking are gendered in this population thus tobacco control and smoking cessation programming should be gender sensitive

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since the 1970s theory and research has examined associations between societal and individual views of aging and midlife health behaviors laterlife chronic conditions biomarkers of aging and mortality this research reports associations with different general and domainspecific indicators of individual views including subjective age and age identity selfperceptions and attitudes to own aging and awareness of own aging conceptual reviews suggest that these indicators are interrelated components of individuals perceptions of their own age and aging although previous studies have examined determinants of individual differences in these indicators in midlife and old age including personality education and current health status surprisingly little is known about their potential longterm associations with poor childhood health this study aims to fill this gap two theoretical perspectives inform our study the stereotype embodiment theory of levy for example describes the ways in which pervasive social attitudes and stereotypes about old age are internalized from childhood onwards and operate below awareness as individuals reach socially assigned chronological age categories associated with old age levy suggests that the age stereotypes begin to become aging selfstereotypes lifecourse and lifespan theories about the development of identity and selfrelated beliefs highlight the influence of lifelong interactions with agestructured social systems and social role transitions in addition to psychological processes such as comparisons between distal and proximal physical psychological and healthrelated markers of developmental change research derived from these two perspectives finds intriguing agerelated crossover patterns in subjective age whereas adolescents generally feel older than their actual age after age 25 young adults report feeling younger and after age 40 individuals generally feel 20 younger than their actual age in another study galambos darrah and magillevans found that unlike 25yearold adults without motor disabilities who typically feel younger than their actual age those with severe physical limitations due to cerebral palsy and spina bifida felt older galambos et al speculated that in addition to experiencing physical challenges young adults with disabilities also have to deal with the negative reactions of others and that these experiences may contribute to them feeling more mature than their peers this speculation is consistent with a finding from schafer that the offtime experience of a mothers death before age 16 was associated with feeling 3 years older than age peers 50 years later despite extensive research documenting the longlasting impact of childhood chronic illnesses and family socioeconomic disadvantage on latelife socioeconomic status chronic morbidity and longevity it remains unclear if poor childhood health also influences latelife perceptions of age and aging in addition to the best of our knowledge little evidence exists about the multivariate relationship between latelife perceptions of age and aging and childhood health after controls for childhood adversity adult health and sociodemographic covariates we use retrospective reports of childhood chronic illness and ratings of childhood health status collected in the health and retirement study to examine these open questions previous studies report that the hrs retrospective childhood health measures are reliable and associated with latelife comorbidity in accord with the proposals of levy and lifespanlifecourse theories we hypothesized that poor childhood health would be related to negative selfperceptions of aging and attenuate the extent that people felt younger than their actual age in addition we expected that these effects would remain after controls for childhood family financial status together with known latelife correlates including latelife comorbidity memory status and sociodemographic factors method sample we drew a subsample of ageeligible nonproxy hrs participants from the 2016 biennial wave who completed a selfadministered psychosocial questionnaire and provided retrospective reports about their childhood health and family history after excluding 414 people with missing covariates the final analytic sample consisted of 5773 midlife and older adults compared with participants with missing data the final analytic sample was younger and more likely to be nonhispanic white married have more years of education better memory fewer adult diagnosed chronic illnesses less negative selfperceptions of aging and to report better selfrated childhood and current health measures table 1 provides details and descriptive information for the two childhood health predictors the two outcome measures and all covariates diagnoses of childhood illnesses prior to age 16 were obtained from 58 of the sample in the 2008 biennial interview and collected from laterborn cohorts when they entered the study we summed reports coded in 15 categories the other category included reports of specific cancers musculoskeletal endocrine reproductive and neurological illnesses selfrated health in childhood was collected prior and in 2008 for 58 of the sample and at study entry in 2010 and 2016 in 2016 hrs collected an 8item measure selfperception of aging derived from the philadelphia morale scale and the berlin aging study five items describe negative evaluations and three are positive the subjective age item asks what age do you feel consistent with the literature we created proportion subjective age discrepancy most participants felt younger than their age 1386 felt the same age as their chronological age and 1084 felt older details for covariates are described in table 1 but we expand a few here age was entered as a continuous variable distributed as follows 4632 were between 50 and 64 3807 were between 65 and 79 and 1561 were 80 and older for analyses we coded four racialethnicity subgroups nonhispanic white african american hispanic and other as an indicator of current financial status we created quintiles of the rand hrs imputed composite for total household wealth adult diagnosed illnesses included reports of high blood pressure diabetes cancer lung heart conditions stroke arthritis and emotionalpsychiatric diagnoses hrs assesses memory using immediate and delayed recall of a list of 10 words presented orally analytic strategy preliminary descriptive analyses were computed on spa and psad the childhood health indicators and 10 covariates following elo we also evaluated the internal validity of the two childhood health measures by determining their relationship with responses to another question included in the hrs childhood measures namely before age 16 year did you miss a month or more of school because of a health problem using a subsample of 4663 participants multivariate multiple linear regression analysis of spa and psad regressed on the childhood health indicators and 10 covariates listed in table 1 we also included two contrast indicators for race ethnicity and four for the wealth quintile gradient all analyses were performed using sas version 94 all pvalues were reported as 2sided and statistical significance was defined as pvalues 05 results in 2016 spa and psad were significantly correlated r 37 interestingly this correlation was highest in midlife r 41 and reduced to r 22 in participants over age 80 reports of childhood illnesses were negatively correlated with selfratings of childhood health consistent with the literature respondents with more chronic health conditions in 2016 perceived their aging more negatively and felt older r 34 and r 17 respectively in addition they reported more childhood illnesses rated their childhood heath as poor and rated their adult health as poor r 13 r 13 and r 44 respectively furthermore consistent with elo we found that participants who reported having more childhood illnesses were more likely to report having missed months of school compared to those with no childhood health conditions χ 2 26954 p 0001 in addition whereas only 544 of participants reported missing school if they rated their childhood health as excellent 5733 of those who rated their childhood health as poor indicated that they had missed a month or more of school χ 2 46942 p 0001 the initial overall mmra model that examined the association of the multivariate set of the spa and psad outcomes with each childhood health predictor revealed statistically significant effects for selfrated childhood health pillais trace 01 f 3962 p 0001 and for childhood health conditions pillais trace 002 f 497 p 01 this mmra model also provides separate multiple regression estimates for each outcome controlling for their covariation both childhood measures were significant predictors for spa and accounted for 2 of the residual variance independent of the covariation with psad multiple r 2 02 childhood illnesses and selfrated childhood health similarly estimates for both childhood measures were significant for psad and accounted for 1 of the variance independent of the covariation with spa multiple r 2 01 childhood illnesses and selfrated childhood health the fully adjusted overall mmra model included controls for current chronic illnesses selfrated adult health memory status all sociodemographic covariates and the interval between childhood and adult measures in this model the effect for childhood illnesses remained significant pillais trace 001 f 349 p 03 however the overall effect for selfrated childhood health was no longer significant pillais trace 0003 f 084 p 43 the separate multiple regression estimates within this fully adjusted mmra model revealed that the partial effect of childhood illnesses was significant for spa but not for psad together the two predictors and 10 covariates accounted for 28 of spa variance and for 10 of psad variance the partial effect for selfrated adult health was strongest overall a followup analysis added a variable to indicate whether or not the childhood illness remained present in adulthood of the 2689 participants who reported a childhood illness 3263 reported still having the condition the addition of this variable did not change the findings reported above discussion to the best of our knowledge this is the first study to examine the role of childhood health on latelife perceptions of age and aging in a large nationally representative sample of older adults furthermore we asked if two indicators of childhood health showed similar relationships with two conceptuallyand statistically related measures of agerelated perceptions spa and psad consistent with conceptual reviews and earlier studies that included both spa and psad we found that spa and psad are interrelated and associated with concurrent health and life contexts whereas kottergrühn et al reported differences in the processes underlying changes in spa and one intriguing insight from the present study is the finding that chronic illnesses in childhood play a longlasting small role in enhancing negative spa but have no direct effect on psad after controls for known strong proximal associations between these views of aging and current comorbidity in line with levys proposals this spa finding suggests that nonnormative potentially stigmatizing healthrelated experiences that have implications for long and potentially recurring absences from school may contribute to individuals dissociating from the healthy age stereotype linked to adolescence and young adulthood perhaps these young adults begin to selfstereotype with negative age characteristics usually associated with older adults this interpretation is consistent with a lifecourse lifespan perspective and suggestions by galambos et al and schafer the selfstereotyping process may be enhanced after individuals reach midlife and encounter new illnesses and additional body reminders of aging new questions about underlying explanatory processes are also opened by the finding that selfrated poor childhood health was not significant after adjusting for 10 indicators of known latelife correlates of spa and psad of note is the relatively stronger partial effect of the associations of current selfrated adult health with psad compared with those for current diagnosed illnesses in part this may reflect shared method variance and the limitations of interpreting residual variance in mmra models in addition previous research suggests that retrospective subjective ratings are less reliable than recall of autobiographical factual information and that latelife subjective age fluctuates daytoday and in response to pain and illness replication and resolution of these findings and interpretation await future research interpretations of the study findings are limited by the lack of earlylife measures of perceptions of aging future studies could model changes in spa and psad after 2008 when most of the retrospective childhood were collected it would also be interesting to examine the effects of childhood health on agecohort and racial ethnic group differences in the intertwining of latelife changes in spa and psad alternatively future studies could examine agecohort and racialethnic group differences in childhood health and their subsequent links with spa psad and other selfrelated views of age and aging and health we included only one indicator of childhood disadvantage but others are available in hrs the findings are of course also limited by selective mortality hrs participants who reported histories of poor childhood health in 2008 may not have survived to complete the 2016 wave despite these limitations this study points to the benefits of extending research on selfperceptions of age and aging to consider developmental precursors not only in early life but throughout the life of individuals supplementary material supplementary data are available at the journals of gerontology series b psychological sciences and social sciences online

objectives age stereotypes and expectations about ones own aging commence in childhood but most research focuses on predictive associations with midlife health behaviors laterlife chronic conditions biomarkers and longevity surprisingly little is known about the role of poor childhood health in these associations this study aims to fill this gap methods using data from the health and retirement study hrs n 5773 aged 5098 we investigated whether diagnosed chronic illness before age 16 and selfrated childhood health predict latelife selfperceptions of aging spa and proportional subjective age discrepancy psad we conducted multivariate multiple regression analysis mmra to determine the joint and partial effects of the two indicators of childhood health models included controls for childhood family financial status as well as latelife selfrated health chronic illnesses memory status and demographic covariates age gender raceethnicity marital status socioeconomic status in 2016 results over and above all covariates and the covariation of the two views of ones own aging the mmra models revealed that the number of childhood chronic illnesses predicted spa but not for psad selfrated childhood health predicted both spa and psad in the unadjusted models but not in the adjusted models discussion this study provides new insight into potential earlylife precursors of selfevaluations of aging in particular childhood diagnoses of chronic illness enhance negative spa up to 50 years later nonnormative experiences related to poor health in childhood are lifelong foundations for socioeconomic status health and for selfrelated beliefs about age and aging

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introduction creating a nationwide demonstration zone for ethnic unity and progress is a necessary step in promoting social progress and development in ethnic regions an important path to enhance the level of ethnic unity and progress in china and an inherent requirement for strengthening the sense of community among the chinese nation in 2021 the cpc central committee general secretary pointed out at the fifth central conference on ethnic work we should deepen the creation of ethnic unity and progress focus on deepening connotation enriching forms and innovating methods and build a normalized mechanism for promoting and educating the chinese nations sense of community this important directive provides fundamental guidance for promoting the construction of demonstration zones for ethnic unity and progress in china in the new era since 2013 the state ethnic affairs commission has successively selected ten batches of demonstration units for ethnic unity and progress as one of the ethnic minority settlements in china hunan deeply implements the spirit of the central and provincial ethnic work conference adheres to the main line of strengthening the awareness of the sense of community for the chinese nation and effectively promotes the deepening and implementation of the work of creating ethnic unity and progress at present there are 48 regions in hunan province that have won the nationwide demonstration unit for ethnic unity and progress as the only ethnic minority township in yiyang city hunan province zhabu hui township has important theoretical and practical significance in creating a demonstration of ethnic unity and progress taking advantage of the opportunity of creation a nationwide demonstration city of ethnic unity and progress based on the field survey this paper summarizes the main measures taken by zhabu hui township to create a ethnic unity and progress demonstration area analyzes the effectiveness of zhabu hui township in creating ethnic unity and progress and extracts the experience and enlightenment of zhabu hui township in creating a ethnic unity and progress demonstration area hoping to provide meaningful reference for other regions to carry out the creation of ethnic unity and progress 2 the general situation of zhabu hui township in hunan province and the effect of creation nationwide demonstration area of ethnic unity and progress overview of zhabu hui township zhabu hui township is the only minority township in yiyang city it is located on the north bank of zijiang river in taojiang county with a total area of 58188km2 it governs 18 villages and neighborhood committees with a total population of 21780the hui and han ethnic groups in the township have lived together for a long time since the founding of the township the people of the two ethnic groups have respected each other and lived in harmony working and living together on this land and drawing a beautiful blueprint for zhabufor a long time zhabu hui township has vigorously promoted spirit of patriotism and has won the titles of nationwide ethnic unity and progress demonstration unit hunan provincial ethnic unity and progress demonstration site hunan provincial ethnic unity and progress model collective etc zhabu hui townships achievements in creating nationwide demonstration area for ethnic unity and progress ethnic unity is the highest interest of all ethnic groups and the lifeline of the people of all ethnic groups in chinato do a good job in ethnic work the most crucial thing is to promote ethnic unityin recent years the party committee and government of zhabu hui township have united and relied on the people of all ethnic groups in the township to put into practice the peoplecentred development ideait has promoted the creation of ethnic unity and progress in five areas strengthening grassroots party building promoting the development of ethnic industries upgrading environmental infrastructure deepening publicity and education strengthening social governance and highlighting the leading role of the construction of demonstration zones strengthen the party building at the grassroots level and consolidate the political foundation adhering to and strengthening the partys leadership is the fundamental guarantee of doing a good job in ethnic work and also the fundamental political guarantee for the establishment of the nationwide ethnic unity demonstration area in zhabu hui townshipin recent years zhabu hui township has focused on hui and han people are close to each other and develop together to comprehensively strengthen the leadership and construction of the partythe first is to implement the responsibility of creating the subject zhabu hui township party committee adhere to a high degree of political consciousness to grasp the main responsibility for the creation of the establishment of a leading group for the creation of the township party secretary as the head from the perspective of attaching great importance to ethnic work promoting the development of economic and social undertakings in the township and safeguarding ethnic unity and social stability the creation of ethnic unity and progress has been integrated into the central work of the township the second is to improve and consolidate the grassroots party building system the grassroots party organization is an important fighting fortress to promote the implementation of the cause of ethnic unity and progresszhabu hui township continuously strengthens the development and training of hui party members selects hui cadres to join the village branch committees strengthens the weak areas of party building in nonpublic party organizations and forms three nonpublic party organizations in 10 private enterprises throughout the township effectively enhancing the appeal of grassroots party organizations and becoming a backbone force in maintaining ethnic unity the last is to strengthen the construction of talent cadre team the party committee of zhabu hui township focuses on the key points insists on making a good reserve of minority cadres and uses the provincial examination to recruit hui cadres at the same time the township party committee has solidly carried out ideological and political education for cadres by inviting members of the county party committees propaganda team to give onsite lectures attend micro party classes conduct micro lectures conduct night schools for cadres learn about building a strong country and carry out practical activities promote the development of ethnic industries and forge the cornerstone of ethnic unity and progress promoting the economic and social development of ethnic areas and promoting common prosperity in ethnic areas are the inherent meaning of realizing the common development and prosperity of all ethnic groups and also the basis for consolidating ethnic unityzhabu hui township abandoned the development thinking of waiting relying and wanting strove to seize the onceinacentury historical opportunity actively strive for various economic development policies issued by the central government to provinces and cities based on the local reality polished the two business cards of blockboard and fresh beef and constantly promoted the cause of ethnic unity and progress into the whole process of the construction of rich fresh portfirstit is relying on blockboard to promote industrial developmentunder the premise of adhering to the market leadership the small board industry will be promoted step by step to take the road of agglomeration cluster and intensive development and the brand of the largest blockboard production base in southern china will be deepenedthe second is to do deep and practical characteristic industries it has carefully created special catering for fivespice beef and continued to promote the declaration of the nationwide geographical indication trademark of zhabu beefallout efforts to promote zhabu beef and whole cow feast brand awareness and reputation taking the mosque provincial beautiful village jungongzui beautiful house nanjing bay characteristic farmhouse as the carrier indepth excavation of characteristic tourism resources continuously improve tourism facilities and constantly improve the basic conditions for leisure tours rural tours and weekend tours lastly the vitality of tourism has been continuously activated relying on the profound ethnic cultural heritage and industrial resources vigorously develop rural tourism and actively explore the development mode of ethnic customs nonheritage culture special industries rural tourism and by organising largescale festivals such as nonheritage cultural festivals and rape flower festivals and launching a number of special farms special farms and special food according to local conditions we will strive to make zhabu a beautiful hometown integrating ethnic customs leisure tourism folklore experience and cultural education improve the construction of environmental infrastructure and help the creation of ethnic unity and progress demonstration a good ecological environment is the inherent requirement of realizing the sustainable development of the chinese nation and the priority area of improving peoples livelihood and wellbeing in recent years zhabu hui township has firmly established and practiced the concept that green waters and green mountains are golden mountains and silver mountains by adhering to the priority of protection and strengthening infrastructure construction it has helped create a demonstration of ethnic unity and progress to show a new atmosphere firstly to effectively optimise the protection of the ecological environment in 2022 zhabu hui township will complete the installation of environmental protection facilities such as organic waste gas and boiler flue gas collection devices of 22 enterprises continuously deepen the special rectification of agricultural surface pollution blacksmelling water livestock and poultry manure straw burning and other special rectificationfully implement the river chief system forest chief system field chief system the yangtze river basin tenyear ban on fishing decisionmaking and deployment it continuously promotes the mutual promotion and integration of zhabus ecological civilisation construction and the creation of ethnic unity and progress and the winwin situation of green and rich secondly upgrading the living environment zhabu hui township continuously deepens the party building guidancegrid managementvolunteer service living environment optimization model explores the public morality • love points system management mechanism and further stimulates the endogenous motivation of the people it has also continued to promote the construction of six ones clean demonstration villages and sanitary toilets paid special attention to the rectification of weak current lines advertising signs disorderly parking and leaning demolition of illegal buildings and implemented greening and quality improvement projectsfinally to improve infrastructure construction zhabu hui township has increased its efforts to build a rural medical and health service system and has endeavoured to solve the problem of access to medical care for the massesit implements the project of cultural benefit to the people organises activities such as square dance for ethnic fitness and ethnic games to enrich the spiritual and cultural life of the masses deepen publicity and education and build a solid ideological foundation for ethnic unity and progress the publicity and education of ethnic unity and progress is not only an important starting point to promote exchanges and exchanges among all ethnic groups but also an important way to build a strong sense of community for the chinese nation in recent years zhabu hui township has taken the building of a strong sense of the community of the chinese nation as the main line and the ethnic unity education month activity and the theme education activity of the chinese nation is close to each other and build the chinese dream together as an important starting point so as to consolidate the ideological foundation of the hui and han ethnic group joint unity and struggle common prosperity and development firstly zhabu hui township promotes the mutual integration and promotion of publicity and education on ethnic unity and progress with the work of the entire township it has incorporated the partys ethnic and religious policies and the traditional virtues of the chinese nation into the studies of the central group of the party committee of the township the theme party day and the evening school for cadresthe use of emerging media and literary works to promote ethnic unity and progress in an allround threedimensional manner it has actively created a strong atmosphere of ethnic unity in which the chinese nation is one family building the chinese dream with one heart and has helped to make the work of creating ethnic unity and progress a household namethe next step is to promote the creation of a civilised zhabu it carries out activities such as selecting the most beautiful zhabu people moral models and good people around them and drives and guides the masses to think of good people and respect virtue and goodness actively organise the learning the golden sentence showing achievements welcoming the 20th party congress theoretical micropresentation and the endeavouring to a new era concentric new zhabu ethnic fitness square dance competition promoting highquality development building concentric new zhabu research and discussion advocating scientific civilised healthy new style the last is to protect and inherit intangible cultural heritage carrying out activities to introduce various intangible cultural heritage projects into schools and villages protecting and passing on hui peoples martial arts threestick drums and other special ethnic cultures and carrying out the declaration of intangible cultural heritage at the same time the township has deeply excavated hui culture traditional costumes legends and stories and historical testimonies by the end of 2022 the township had 1 provincial nonlegacy 4 municipal nonlegacy 1 county nonlegacy and was awarded the first batch of municipal nonlegacy village and town demonstration sites in yiyang city the fundamental question of whether ethnic work can be done well is whether the leadership of the party is strong and effective the creation of ethnic unity and progress is a social system engineering under the leadership of the party with the masses of all ethnic groups as the main body and guaranteed by the power of the state first of all the partys leadership should be integrated into all efforts to create ethnic unity and progress the effective play of the leading role of party building cannot be achieved without strong grassroots party organizations grassroots party organizations in ethnic areas are the main force and leader in implementing the creation of ethnic unity and progress it is important to continue to promote grassroots governance led by party building strengthen the political leadership function of trust and effectively fulfil the main responsibility and the first responsibility of party committees and governments guided by the important ideas of the cpc central committee on strengthening and improving ethnic work the creation of ethnic unity and progress will be incorporated into the publicity and education on ethnic unity and progress interaction and exchanges between various ethnic groups and the deepening and expansion of the creation of work so as to prompt the construction of the model area for the progress of ethnic unity and the economic and social development of the ethnic regions to be mutually integrated and mutually reinforcing and to resonate at the same frequency secondly it is necessary to improve the institutional mechanism for the creation of ethnic unity and progress a strong institutional framework is an important link and guarantee for promoting ethnic unity and progress it is necessary to strengthen organizational leadership mechanisms such as leaders and party committee secretaries to provide fundamental guidance and direction for demonstration creation actively exploring the establishment of institutional mechanisms with the participation of the whole society establishing alliances for creation and strengthening the linkage of creation in various ethnic regions building a longterm mechanism for ethnic unity and progress and grasping the relay baton to stabilize ethnic unity at the same time at the same time it is necessary to establish and improve mechanisms for coordinating and promoting the creation of ethnic unity and progress as well as for assessment and supervision so as to create a favourable external environment and provide a solid guarantee for the creation of ethnic unity and progress it is necessary to promote the formation of a newera pattern of the partys ethnic work under the unified leadership of the party committee managed by the government in accordance with the law led and coordinated by the united front work department with the ethnic work departments fulfilling their duties and responsibilities full cooperation among all departments and joint participation by the whole society finally it is important to focus on building a talent pool in ethnic areas in accordance with the four special requirements put forward by the cpc central committee for cadres in ethnic areas in the new period efforts are being made to build a highquality professional team that is loyal clean and responsible for ethnic unity and progress a mechanism has been set up for the cultivation and introduction of talents in ethnic areas and the sources of talents have been broadened attention should be paid to the training use exchange and practice of ethnic minority cadres and talents giving full play to the important role of ethnic minority cadres and talents in ethnic unity and providing a steady stream of impetus and vitality for the creation of ethnic unity and progress reflection and inspiration on creating a nationwide ethnic unity and progress strengthening the sense of community among the chinese nation and creating a focused mainline for ethnic unity and progress the cause of ethnic unity progress is a foundational cause for forging a sense of community for the chinese nation 1 the sense of community for the chinese nation is the foundation of ethnic unity which requires that the forging of a firm sense of community for the chinese nation be carried out throughout the entire process of creating ethnic unity and progress firstly there is a need to strengthen the interaction exchange and integration of all ethnic groups promoting ethnic communication exchange and integration requires creating social conditions for co construction learning and sharing among all ethnic groups in the economy culture and language and the creation of ethnic unity and progress is a concentrated reflection of these social conditions promoting extensive communication exchange and integration among all ethnic groups is an important way to promote the creation of ethnic unity and progress and promoting extensive communication exchange and integration among all ethnic groups is also one of the goals aimed at promoting ethnic unity and progress strengthening interaction exchanges and integration among ethnic groups requires the promotion of the establishment of mutually embedded social structures and community environments and the gradual expansion of spatial embeddedness to economic cultural social and psychological embeddedness in a comprehensive manner we must do a good job of managing and servicing urban ethnic minority migrants and actively create social conditions and environments in which all ethnic groups can live together learn together work together and have fun starting with everyday aspects of their lives such as living and living medical care and schooling work and learning and cultural and recreational activities in this way we can provide a wide range of stage for the wide range of interactions and exchanges between the various ethnic groups and create a strong atmosphere for the creation of ethnic unity and progress secondly a common spiritual home for all ethnic groups should be constructed it is necessary to actively guide the people of all ethnic groups to firmly establish the community concept of shared weal and woe honor and disgrace life and death and destiny take strengthening identity as the goal take socialist core values as the guide and strengthen the education of the chinese nation community and four history to promote the promotion popularization and use of nationwide common language and writing in ethnic regions we should use new media and technologies to gather consensus and promote the internet to become the largest increment in building a shared spiritual home for the chinese nation and forging a sense of community for the chinese nation finally it is necessary to deeply excavate and pass on the development of the outstanding traditional culture of the nation cultural identity is more conducive to national unity 2 cultural identity is the deepest level of identity and the excellent traditional culture of all ethnic groups is an integral part of chinese culture language and writing festivals art and other forms should be used to establish and highlight the symbols of chinese culture and the image of the chinese nation shared by all ethnic groups to promote the creative transformation and innovative development of the outstanding traditional cultures of all ethnic groups dig deeper into and highlight the contents of the cultures of all ethnic groups that are conducive to forging a firm sense of community for the chinese nation and strengthening ethnic unity and progress at the same time it is necessary to inherit protect and develop ethnic minority cultures through platforms such as ethnic minority cultural performances sports competitions and intangible cultural heritage continuously enhance cultural integration and convergence among ethnic groups enhance chinese cultural identity and consolidate the ideological foundation of ethnic unity and progress consolidate the foundation of development and lay a solid material foundation for the creation of ethnic unity and progress the development power of the nation is in harmony with the national unity 3 in the new journey towards the great rejuvenation of the chinese nation the realisation of the common prosperity and development of all ethnic groups is the starting and ending point of the partys ethnic work promoting the development of ethnic regions is not only the overall key to solving various problems in ethnic regions but also a solid foundation for the creation of ethnic unity and progress promoting the creation of ethnic unity and progress is an important way to implement the theme of ethnic work in the new era the common unity struggle and prosperity of all ethnic groups firstly promote the creation of ethnic unity and progress around development adhering to the belief that all ethnic groups are one family and all families must lead a good life the government has placed a more prominent strategic position on accelerating the development of ethnic minorities and ethnic regions it is necessary to closely integrate the creation of ethnic unity and progress with development and to effectively link the consolidation of poverty alleviation in ethnic areas with rural revitalisation relying on local resource endowments and adhering to the concept of green development we will actively explore the construction of a number of research education and training bases for the creation of ethnic unity and progress as well as demonstration sites for ethnic unity and progress in urban communities explore new modes of promoting the development of ethnic villages through the integration of agriculture culture and tourism so as to promote sound and rapid economic development in addition while emphasizing the development of material civilization emphasis is placed on the improvement of spiritual civilization and the two work together to form a collaborative force secondly continuously improving peoples livelihoods and enhancing their wellbeing we should take measures such as the border revitalization project and the rural revitalization strategy as important measures use domestic and foreign resources and hightech to promote the development of ethnic areas strengthen the public service capacity and infrastructure construction of ethnic areas continuously improve the level of social security and continuously improve the rural living environment effectively addressing the most concerning issues of all ethnic groups such as education employment and healthcare implementing development to improve peoples livelihoods benefit the local community and enhance ethnic unity continuously enhancing the sense of gain happiness and security of all ethnic groups and realizing their aspirations for a better life finally promote industrial development based on local conditions industry is the foundation for promoting the development of ethnic areas and it is necessary to cultivate and strengthen the advantageous characteristic industries based on the actual situation of ethnic areas actively strive for and make good use of the new policies funds and projects tilted by the party and the state towards the ethnic areas to boost the development of the industries set up a new concept of development promote the upgrading of the industries with reforms and innovations optimise the industrial structure and the mode of development enhance the modernised quality of the tertiary industry while reforming the secondary industry consolidate the fundamental position of the primary industry promote the highquality development of the industries and consolidate the material basis of creation of the progress and solidarity of the ethnic unity deepen publicity and education to create a cohesive force for ethnic unity and progress china is a multiethnic country education for ethnic unity and progress is a longterm strategy to unite all ethnic groups and the country in harmony and stability 4 ，it is also the core content and an important part of the indepth construction of ethnic unity and progress firstly strengthening education on the sense of community of the chinese nation to make people of all ethnic groups realize that they are a member of the chinese nation and to educate and guide them to firmly establish the concept of shared weal and woe honor and disgrace life and death and destiny guided by socialist core values promote ideological and political education for young people effectively enhance the five identifications of people of all ethnic groups through popular propaganda and education methods and guide them to establish the correct five views to excavate the excellent culture and common history of all ethnic groups promote chinese cultural identity consolidate the correct historical view of four commonalities enhance the awareness of the sense of community for the chinese nation of all ethnic groups promote the common breathing and destiny of all ethnic groups and consolidate wisdom and strength to promote ethnic unity and build a beautiful home together secondly innovate the carriers and methods of promoting ethnic unity and progress in education we need to establish a normalized mechanism for ethnic unity and progress education increase the emphasis on propaganda and education incorporate ethnic unity education into the entire process of nationwide education cadre education and social education and build an educational platform that integrates classroom teaching social practice and theme education on the one hand traditional ethnic festivals and activities can be used to promote the achievements of ethnic unity and progress on the other hand new media and technologies such as the internet and integrated media can be used to create tangible new carriers and methods allowing the people to continuously internalize and consciously practice the concept of ethnic unity and progress in their daily work and life atmosphere we should take the creation of grassroots units as a prerequisite summarize the experience of creation and continuously expand the scope of creation from point to surface finally establish advanced models and highlight demonstration and leadership the creation of ethnic unity and progress is based on the concept and model of ethnic unity and progress and the establishment is based on the mechanism of sustainable development rather than the end of creation we should give full play to the exemplary and leading role of ethnic unity and progress in creating exemplary organization and individuals enhance the awareness of the masses of the people to create form a joint force to create and constantly promote ethnic unity and progress to create a solid sense of community for the chinese nation conclusion the construction of the ethnic unity and progress demonstration zone is a mission entrusted to it by the new era and its fundamental direction is to adhere to the correct path of resolving ethnic problems with chinese characteristics the zhabu hui townships practice of creating a nationwide model area for ethnic unity and progress can provide some experience for the construction of other areasbut at the same time zhabu hui township in the new era of the new journey in the construction but also to adhere to the leadership of the party improve the system of laws and regulations casting the sense of community of the chinese nation consolidate the foundation of development and deepen the publicity and education to write a new chapter in the cause of ethnic unity and progress

the creation of ethnic unity and progress is the proper meaning of building the sense of community for the chinese nation and it is also an important starting point for comprehensively promoting the highquality development of chinas ethnic workthe creation of the nationwide ethnic unity and progress demonstration zone in zhabu hui township has achieved positive results in grassroots party building industrial development infrastructure construction publicity and education social governance and demonstration guidance the summary of the experience and inspiration of the creation of zhabu hui township has important theoretical and reference significance for the creation of ethnic unity demonstration zones in other regions

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introduction in recent years most countries have been facing the problem of the loss of rural teachers governments and academic circles worldwide are attempting to analyze the causes of the problem and formulate policies accordingly to explain the reasons behind the hemorrhage among qualified teachers researchers have drawn attention to the identity definition used in the philosophy and social sciences specifically occupational identity serves as a critical driving force behind teachers selfgrowth and professional development thereby determining their attitude cognition emotion and behaviors toward their profession to a substantial extent furthermore the development of occupational identity represents a fluid and changeable social process that involves individual and collective perception and differentiation owing to its complex and multifaceted nature occupational identity is associated with environmental concerns such as educational relationships and experiences and individual characteristics while interacting with their environment individuals identity formats within social contexts particularly for the student teachers a previous study identified certain factors influencing the career choices of students meanwhile research and empirical findings from different nations demonstrate that students family backgrounds abilities personalities and motivations are the key factors that determine their selection of teacher education majors in addition family and school environments constitute the major contextual factors that shape the studytowork transition for instance montmarquette et al confirmed that the family wealth and socioeconomic status of adolescents are positively related to their educational choices consistent with this students seek emotional support from their families which leads to the development of positive behavior tendencies among them as a positive psychological capital thus effectively enhancing their professional identity as a result family support results in higher levels of career adaptability noticeably career adaptability is interrelated with the development of a strong occupational identity based on this college students may experience identity diffusion in families with poorly defined boundaries therefore students prefer to avoid an occupational choice or commit to an option without exploration to fulfill parental expectations at the same time professional commitment is a psychological reaction to an individuals profession which is originally shaped by fundamental education such a psychological reaction tends to be stable during the period of graduation additionally this reaction is characterized by continuous variation following graduation for normal students professional commitment refers to whether they plan to work in their professional field after graduation reportedly chinese education students come from less privileged backgrounds in terms of socioeconomic status and academic preparation furthermore a significant number of these students do not intend to commit to teaching as a lifelong career as a result it is critical to strengthen normal students professional dedication therefore improving students professional commitment has important benefits for their academic performance and career development which is an issue that teachers and normal colleges should consider as a form of free education and national funding local publicly funded students have already signed contracts with the local government before leaving their hometowns thereby agreeing in advance to return to local primary and middle schools in the rural areas of their hometown for employment after graduation consequently the role of psychological capital and professional commitment between family environment and occupational identity can improve normal students ability under pressure and maintain an optimistic attitude toward professional study and future work which can be intervened to enhance the psychological capital and occupational identity of students a total of 28 chinese provinces have implemented such policies with nearly 40000 teachers and students of primary and secondary schools being supplemented to rural and remote regions each year after more than 10 years of exploration however after several years of implementation it has reflected problems of immature career choices and brain drain hence in contrast to ordinary normal students strengthening the occupational identity among publicly funded students becomes an imperative goal of this policy to carry out the smooth performance despite the practical and theoretical significance of occupational identity very little research has been undertaken on the relationship between family influence and occupational identity in line with this it is essential to understand the factors that are perceived as significant by the local publicly funded students from the perspective of occupational identity thus to explore its underlying mechanisms for enhancing vocational identity among local publicly funded students this study addresses two major research questions 1 what are the factors that affect the occupational identity of publicly funded students at local normal colleges in their future careers 2 what is the association among those factors of publicly funded students at local normal colleges literature review and theoretical background family environment and occupational identity family is the first place for teenagers to study and live family hard environments and soft environments closely correlate with teenagers selfefficacy of career decisionmaking career exploration behavior and planning normal students occupational identity denotes their perception and experience of the profession they will engage in which is the psychological basis and preparation for the teaching profession the key factor for teachers resignation and the most lasting source of teachers emotions the economic cultural and social resources owned by different families parents educational attitudes toward their children educational methods and educational expectations exert a critical impact on their childrens educational choices to varying degrees the investigation of the development stage revealed that the development of teachers occupational identities follows an internal phased track of knowledge ideas and behavior some studies demonstrated that families cultures could shape individual professional values and professional ideas the intimacy of the family environment influences individual selfcognition and professional behavior and enhances selfefficacy the control of the family environment can standardize behavior and morality deepen the internalization of norms and promote the unity of knowledge and practice in addition personality qualities such as diligence and tenacity and behavior norms and family culture that have been developed for a long time in the process of family development and restrict family members exert a subtle impact on students learning consciousness in the same vein family background social status and environment exhibit a substantial impact on the future college expectations and career choices of high school seniors as a special group undertaking the cultivation of rural education teachers through practice in recent years publicly funded normal students have shown great randomness and uncertainty in policy cognition voluntary reporting teaching motivation and professional preferences and are more susceptible to the influence of the family environment accordingly the following is hypothesized hypothesis 1 family environment positively affects the occupational identity of publicly funded normal students the mediating role of psychological capital psychological capital is an individuals psychological potential and positive advantage that can encourage employees to complete their inrole behavior and display organizational citizenship behavior aimed at helping others meanwhile some studies defined the four positive psychological states of selfconfidence hope optimism and tenacity as the core concept of psychological capital cole claimed that psychological capital could mediate other variables to affect employee behavior he took unemployed employees as the research object and found that psychological capital plays an intermediary role in correlating subjective satisfaction after unemployment and reemployment behavior renn and vandenberg established that psychological factors play an intermediary role in the influence of personal factors although no research has been conducted on the role of psychological capital in the family environment on normal students occupational identities in pedagogy studies have confirmed that family intimacy exerts a positive predictive effect on college students psychological capital a good family environment can not only directly affect the individuals psychological capital but also make the individual more aware of the support from friends and others outside the family besides some studies confirmed that professional identity and psychological capital as intermediary effects could significantly enhance college students employability college teachers professional honor can markedly predict teachers professional success and professional satisfaction through psychological capital intermediary variables this provides a certain basis for the intermediary role of psychological capital in this study individuals living in a good family atmosphere can feel love and support the family environment promotes the improvement of their psychological capital by influencing their optimistic and positive personality traits which might affect their behavior attitude and choices accordingly the following is hypothesized hypothesis 2 psychological capital plays an intermediary role in the influence of family environment on occupational identity moderating role of professional commitment the concept of professional commitment stems from organizational commitment and professional commitment the mature threefactor model involves emotional commitment normative commitment and continuing commitment accordingly professional commitment refers to a commitment to professional objectives beliefs values and willingness to continue in a specific profession individuals with a high level of professional commitment put extra emphasis and priority on their profession as well as their peers in the professional community the career of college students is professional learning the commitment to professional learning reflects the positive attitude and behavior of college students recognition love and willingness to make corresponding efforts and exhibit good behavior reportedly the initial teaching commitment of preservice teachers after completing the learning and training during teacher education closely correlates with whether they choose the teaching profession in the future besides the 1st years of teaching constitute the entry phase to the profession and are perceived as a phase of critical importance for ascertaining the professional identity of a new teacher occupational identity is primarily reflected in individual value evaluations or judgments on different characteristics of teachers professions professional commitment reflects the individuals psychological or emotional connection to the teachers career identity is based on individual emotional cognition and stable psychological or emotional connection is reflected in the value judgment of professional attitude according to resource conservation theory individuals can use their resources to handle stress and meet the needs of the environment to attain positive results in terms of the mechanism of professional commitment on normal students occupational identities studies have established that college students professional commitment significantly correlates with learning efficacy in a study the learning efficacy of college students in the highcommitment group was markedly higher than that in the lowcommitment group moreover a significant positive correlation was found between emotional commitment ideal commitment and selfefficacy the achievement motivation of college students also correlates with professional commitment college students with low professional commitment levels are more likely not to pursue a relevant job after graduation which not only wastes educational resources but also reduces their enthusiasm for studying it can be inferred that individual traits affect individual attitudes behaviors and allocations of resources professional commitment as their psychological or emotional connection to their future career not only affects the shaping of individual psychological positive traits in different family environments but also acts as an individual trait to handle academic or professional pressure and exhibit good competence accordingly the following are hypothesized hypothesis 3 professional commitment directly regulates the correlation between family environment and occupational identity hypothesis 4 professional commitment regulates the impact of the family environment on the psychological capital of publicly funded normal students when professional commitment is high the impact of the family environment on psychological capital is weak when professional commitment is weak the impact of the family environment on psychological capital is strong hypothesis 5 professional commitment has a moderating effect on the mediating role of psychological capital in the correlation between family environment and occupational identity with high professional commitment psychological capital exerts a stronger positive impact on occupational identity in summary based on previous studies we created and relied on the following theoretical model as illustrated in figure 1 methods samples and procedure we selected freshmen to seniors from nine majors at seven normal universities in sichuan to participate in the survey which used cluster sampling and online questionnaire methods the researchers randomly selected a class of publicly funded normal students from seven schools contacted the class counselor to send the network questionnaire link to the entire class asked each student to carefully complete the questionnaire checked the completion time and reminded students who did not answer in time a total of 419 questionnaires were received after excluding the questionnaires with outliers 395 valid samples were obtained and the sample effective rate was 943 before data analysis data cleaning is performed in accordance with the subsequently specified process and standards first data entry errors are checked such as an extraneous 7 on the sixpoint likert scale second unusual cases are identified and removed including missing data appearing in a nonrandom fashion cases in which the same option is selected 50 of the time missing data constituting 25 of the whole number of items and the results in which the creative achievement zscore is 3 which are identified as data anomalies or outliers afterward 24 participants are excluded from the original sample after data cleaning consequently 395 participants were chosen for the following data analysis process the demographic variables of the total sample were as follows 69 male students and 326 female students 98 only children and 297 nononly children and 32 from teachers families and 363 from nonteachers families in addition 11 students were from chengdu 172 from mianyang deyang and other cities and prefectures with the top 7 gdp in 2019 68 from liangshan neijiang and other cities and prefectures with the top 813 gdp in 2019 and 142 from panzhihua ziyang and other cities and prefectures with the top 1421 gdp in 2019 and 2 from outside sichuan province then 136 students were freshmen 67 sophomores 131 juniors and 61 seniors to ensure the studys reliability and validity the measurement questionnaires used were mature questionnaires that had been repeatedly used previously instruments occupational identity scale the occupational identity scale for publicly funded normal students compiled by zhao hongyu is categorized into three dimensions namely internal value identity external value identity and will behavior identity with a total of 15 questions internal value identification denotes the value judgment of inherent work attributes such as work content and mode external value identification denotes the value judgment of professional social attributes such as the working environment and social status will behavior identity denotes the behavior tendency driven by internal and external value identities the scale adopts the fourpoint scoring method where one point represents completely inconsistent and four points represent very consistent the higher the score the higher the sense of identity in this study the internal consistency reliability of the scale was 0924 psychological capital scale the psychological capital scale developed by luthans and revised by song hongfeng for chinese college students is categorized into four dimensions namely selfefficacy hope optimism and tenacity with a total of 16 questions the scale adopts the fivepoint scoring method where one point represents complete noncompliance and five points represent complete compliance the higher the score the more positive the psychological state in this study the internal consistency reliability of the scale was 0876 professional commitment scale the scale for college students professional commitment compiled by lian et al is divided into four dimensions namely emotional commitment ideal commitment normative commitment and continuous commitment with a total of 27 questions the scale adopts the fivepoint scoring method where one score represents complete noncompliance and five scores represent complete compliance the higher the score the higher the degree of commitment to the major in this study the internal consistency reliability of the scale was 0863 subscales in this study three scales of intimacy culture and control with high reliability were selected the answer no is scored 0 while the answer yes is scored 1 the higher the score on the intimacy dimension the higher the degree of help and support among family members the higher the score on the cultural dimension the higher the degree of family participation in cultural activities moreover the higher the score on the control dimension the stronger the fixed family rules and procedures representing the family environment in this study the internal consistency reliability of the intimacy scale was 0536 the culture scale was 0510 and the control scale was 0750 family environment scale data analysis we analyzed the data in four steps first we performed the common method deviation analysis descriptive statistical analysis correlation analysis independentsample ttest and oneway anova using spss 22 second we conducted four confirmatory factor analyses and reliability analyses to measure the construct validity and reliability of the scales then we created a structural equation model with a secondorder stereotype latent variable to confirm our theoretical model third using the nonparametric percentile bootstrap method with deviation correction we tested the mediating effect of psychological capital fourth the latent regulatory structural equation was used to fit the models of independent variables dependent variables intermediary variables and regulatory variables of note all cfa and sem analyses were conducted with mplus 71 the models were tested using maximumlikelihood estimation of the sample covariance matrix results common method deviation analysis in the research design procedure the questionnaire was arranged randomly and some items used reverse questions and anonymous questionnaires to control the possible homologous variance after data collection harman used the singlefactor analysis test method of integrating all measurement topics into one variable and used the principal component analysis method to extract 21 factors with characteristic roots 1 with a cumulative interpretation of 63339 of which the first principal component factor explained 19161 of the variation which was 50 of the variation interpretation the data showed that the common method deviation did not exert a significant impact on the conclusion cfa and reliability as suggested by fornell and larckers suggestions standardized factor load coefficients composite reliability convergent validity and discriminant validity were used to test the models reliability and validity in this study all cfa and sem analyses were conducted using mplus 71 moreover the models were tested using maximumlikelihood estimation of the sample covariance matrix if the factor load is 07 the constituent reliability is 07 and the convergent validity is 05 the model is considered to have good validity and if the square root of convergent validity is greater than the correlation coefficient of each latent variable it reveals that the measurement model has good discrimination the occupational identity scale includes three dimensions namely internal value identity external value identity and will behavior identity the fitting indexes of the secondorder model were as follows χ 2 df 195 cfitli 101 rmsea 0049 and srmr 0035 the standardized factor load of each observed variable was 07 in addition the combined reliability of the three dimensions was 0912 0825 and 0798 respectively which were greater than the recommended 07 furthermore the convergent validity was 0723 0612 and 0597 respectively which were greater than the recommended 05 hence the model had good convergence the psychological capital scale includes four dimensions namely selfefficacy hope optimism and tenacity the fitting indexes of the secondorder model were as follows χ 2 df 38 cfitli 101 rmsea 0086 and srmr 0043 which fulfilled the recommended reference values the standardized factor load of each observed variable was 07 the combined reliability of the four dimensions was 0707 0754 0747 and 0797 respectively all greater than the recommended 07 moreover the convergent validity was 0546 0535 0598 and 0568 respectively which were greater than the recommended 05 hence the model had good convergence the professional commitment scale includes four dimensions namely emotional commitment ideal commitment normative commitment and continuing commitment the fitting indicators of the secondorder model were as follows χ 2 df 34 cfitli 102 rmsea 0079 and srmr 0052 which fulfilled the recommended reference values the standardized factor load of each observed variable was 07 and the combined reliability of the four dimensions was 0780 0804 0831 and 0747 respectively all greater than the recommended 07 furthermore the convergent validity was 0516 0506 0555 and 0582 respectively which were greater than the recommended 05 hence the model had good convergence the family environment scale includes three dimensions namely intimacy culture and control the fitting indexes of the secondorder model were as follows in table 1 χ 2 df 141 cfitli 101 rmsea 0032 and srmr 0039 which fulfilled the recommended reference values the standardized factor load of each observed variable was 07 the combined reliability of the three dimensions was 0726 0705 and 0746 respectively which were greater than the recommended 07 and the convergent validity was 0599 0542 and 0588 all greater than the recommended 05 hence the model had good convergence tables 2 3 present a summary of the cfa item indices reliability and factor loadings for the stereotype model descriptive statistics and correlation analysis we used spss 220 to statistically analyze the mean standard deviation and correlation of each variable according to table 4 the average of the overall level of family environment was 0528 which was at the medium level suggesting that the overall family environment of publicly funded normal students was relatively general the average scores of occupational identity and psychological capital were 318 and 380 respectively suggesting that the overall level of psychological capital and the sense of identity with teachers profession of publicly funded normal students were at the uppermiddle level while the average value of professional commitment was 492 suggesting that publicly funded normal students showed love and recognition for their major as well as a good attitude and positive behavior ttest and oneway anova analysis in addition the independent sample ttest showed that there was no statistically significant gender difference in occupational identity no statistically significant difference in whether students came from teachers families and no statistically significant difference in whether they were an only child the oneway anova showed a significant difference between freshmen and juniors and juniors occupational identity was significantly higher than that of freshmen from the perspective of students origin no significant difference was found in occupational identity that is no statistically significant difference was found in occupational identity between publicly funded normal students from areas with high or low economic ranking a test of the mediating e ect of psychological capital before the intermediary effect test the measurement model without the intermediary effect was tested the results revealed that the measurement model fitted well χ 2 df 2 rmsea 0047 90 confidence interval cfi 0879 tli 0872 srmr 0056 per the mediating effect test based on the structural equation proposed by wen et al the first step was to build an sem from independent variables to dependent variables the second step was to build an sem incorporating intermediate variables to attain the ci based on the bootstrap method as the sampling distribution of the mediating effect ab often does not obey the normal distribution the nonparametric percentile bootstrap method with deviation correction was used to estimate the ci of the mediating effect to attain the robust standard error ci of parameter estimation if the 95 ci does not contain zero it means that the statistics are significant the first step was to test the direct effect of family environment on occupational identity the results showed that the model fitted well χ 2 2176563 cfi 0878 tli 0870 rmsea 0047 90 ci srmr 0059 after controlling the variables such as gender whether they come from the teachers families whether they were the only child grade and place of origin the family environment exerted a significant predictive impact on occupational identity and the explanation for the variation of occupational identity was 239 hence hypothesis 1 is confirmed the second step was to add psychological capital as a mediating variable based on the original model figure 2 illustrates the mediating effect of psychological capital the results showed that the model fitted well χ 2 2160336 cfi 0877 tli 0870 rmsea 0047 90 ci srmr 0057 the variation explanations of psychological capital and occupational identity were divided into 838 and 739 psychological capital exerted a significant predictive effect on occupational identity the prediction of family environment on occupational identity was not significant in addition the mediating effect of psychological capital between family environment and occupational identity was established thus psychological capital was found to play a complete mediating role in the correlation between family environment and occupational identity hence hypothesis 2 is confirmed the moderation e ect of professional commitment according to fang and wen the fitting test of the independent variable dependent variable intermediate variable and regulatory variable models was conducted using latent modulated structural equations in the test of the latent regulation effect the traditional regression model does not consider the measurement error of the index which generally distorts the parameter estimation results however lms has unique advantages and does not need to construct the product index avoiding the problem of inconsistent parameter estimation due to the generation of different product indexes also it does not require the interaction term to obey the normal distribution thus avoiding the estimation deviation due to the nonnormal distribution of the product term as suggested by maslowsky et al first the main effect of professional commitment was added per the intermediary model the results revealed that β 0228 p 005 and the direct moderation effect is not significant hence hypothesis 3 is not confirmed according to muller et al if the direct path is not regulated a regulated mediation model is established the second step was to establish the benchmark model m0 without potential interaction terms the results revealed that the model fitted well χ 2 2181455 p 0001 cfi 0877 tli 0869 aic 29849424 rmsea 0047 90 ci of rmsea and srmr 0057 the third step was to establish and add latent regulation item 1 × professional commitment and potential regulation item 2 × regulated mediation model m 1 of professional commitment the results showed that aic 29849329 and the aic value remained unchanged compared with the benchmark model m0 suggesting that the adjusted sem model m 0 has not deteriorated compared with the benchmark sem model meanwhile the loglikelihood ratio test was used to compare the h 0 value in the benchmark model and calculate the 2ll value the loglikelihood of the mediation model with adjustment was 14755344 which increased by 0368 compared with the loglikelihood value of the benchmark model that is 2ll 0368 the difference value of the degree of freedom of the model parameters was 1 and the χ 2 test of the 2ll value was figure the mediating e ect of psychological capital p p p significant the mediation model with regulation was better than the benchmark model thus professional commitment exerted no significant moderating effect on family environment and psychological capital furthermore professional commitment exerted a significant moderating effect on the correlation between psychological capital and occupational identity hence hypothesis 4 is not confirmed while hypothesis 5 is confirmed to more clearly reveal the correlation between psychological capital and the interaction effect of professional commitment a simple slope test was conducted to test the mechanism of regulatory effect based on the standard deviation of professional commitment above and below the mean drawing a simple interaction effect analysis chart demonstrated that the intermediary process of family environment affecting occupational identity through psychological capital was regulated by professional commitment in addition professional commitment played a positive regulatory role between psychological capital and occupational identity for publicly funded normal students with high professional commitment the positive impact of psychological capital on occupation identity was found to be stronger discussion the occupational identity of publicly funded normal students influences the quality of normal students training and the cultivation of rural teachers taking the publicly funded normal students in local normal universities as the research object this study investigated the mediating and moderating effect of the family environment of publicly funded normal students on occupational identity as well as examined the combined effect of psychological capital and professional commitment variables the findings elucidated how the family environment of normal students affects their occupational identity the model demonstrates that environmental factors affect the internal value judgment of publicly funded normal students and then affect individual occupational identity characteristics of the occupational identity of publicly funded normal students the results revealed that publicly funded normal students occupational identity as teachers is at a medium level and they show a good attitude and positive level toward their major in addition we explored the correlation between demographic variables and the occupational identity of publicly funded normal students the findings revealed that gender exerts no significant impact on occupational identity nevertheless the difference in the loss of teachers gender is a matter of great concern previous studies claimed that the loss rate of female teachers is lower because of their traditional role orientation while the loss rate and career change rate of male teachers are higher this study confirms no difference in job identity between student teachers in terms of gender the reason for the high turnover rate of male teachers could be more due to the career development issues and challenges faced after service second whether an individual is an only child whether he comes from a teachers family and different student sources are not the main factors affecting the occupational identity of normal students significant differences exist in occupational identity between juniors and freshmen with the increase in grades the occupational identity of normal students revealed an upward trend suggesting that normal education in the university plays a positive guiding role in the cultivation of students occupational identity attitudes with the learning of normal courses and the perception of internships in educational practice students can further feel a sense of value and happiness as teachers enhancing their occupational identity psychological capital is totally mediated by the correlation between family environment and occupational identity this study verifies that the family environment exerts a positive predictive impact on occupational identity which is completely mediated by psychological capital the higher the psychological figure the moderation e ect of professional commitment capital of publicly funded normal students with a good family environment the higher the sense of occupational identity this result not only validates the previous research but also draws new conclusions on the one hand the family environment exerts a positive impact on occupational identity the family environment with a high degree of intimacy rich culture and low control positively correlates with the occupational identity of publicly funded normal students which can be explained by psychological capital the parentchild attachment relationship and personality quality attained by the family are similar to the habit proposed by bourdieu which imperceptibly shapes psychological capital and promotes the recognition of the teachers profession in addition a good family environment leads to a good attachment relationship between parents and children which can be elucidated by psychological capital in addition good parentchild attachment helps to improve teenagers psychological capital form good selfawareness and develop a more positive explanation of others and events this internal psychological demand can be interpreted as psychological capital positive evaluation of the environment and good expectation of the possibility of success which is based on the effort and persistence toward the goal reportedly resilience hope and optimism correlate with employee satisfaction and job happiness when individuals are in a satisfied and pleasant psychological state they are more likely to have higher recognition of their profession or occupation a good family environment nurtures teenagers positive emotions individuals have tenacity hope and optimism which usually results in teenagers being full of selfconfidence and positive optimism this makes it simpler for them to attain satisfaction after success enabling them to treat their decisions more actively on the other hand the psychological capital of publicly funded normal students is totally mediated by the correlation between family environment and occupational identity which helps to elucidate the formation factors of publicly funded normal students occupational identity further deepening the understanding of the correlation between family environment and occupational identity it has been considered that adults after work have high psychological capital which usually makes individuals confident optimistic overcome difficulties strive hard exhibit positive emotions attain a sense of accomplishment after success and then bring a sense of satisfaction making them more willing to work in the organization however as student teachers publicly funded normal students have not yet entered the field of work is this groups occupational identity also related to psychological capital this study confirms that psychological capital factors exert a significant impact on the occupation identity of publicly funded normal students although the orientation factors of publicly funded normal students differ from ordinary normal students and their cognition of teachers careers could be vague in the next few years of college life when we really learn and understand the characteristics and requirements of the teaching industry from the theoretical and practical levels a large part of their expectations for the teacher industry and their evaluation of whether they are suitable for the teacher industry still stems from psychological capital factors besides the shaping of psychological capital is not achieved overnight a good family environment promotes the improvement of publicly funded normal teachers psychological capital and a higher psychological capital can augment the occupational identity of the teaching industry professional commitment plays a positive regulatory role between psychological capital and occupational identity this study establishes that good professional commitment plays a positive role in promoting the occupational identity of publicly funded normal students previous studies explored the impact of teacher support and teaching efficacy on occupational identity but this study investigates the impact of another variableprofessional commitment the sem showed that the direct regulatory effect of professional commitment on family environment and occupational identity was not significant in addition professional commitment was found to play a regulatory role in the intermediary process of family environment psychological capital occupational identity which is manifested in that the second half of the intermediary chain is regulated by professional commitment specifically the interaction between professional commitment and psychological capital exerts a significant positive predictive impact on occupational identity professional commitment might enhance occupational identity by enhancing psychological capital together with the results of relevant analyses professional commitment is conducive to the improvement of occupational identity with the enhancement of professional commitment the impact of the family environment tends to weaken perhaps because when individuals start college life the emotional and ideal source of their teachers industry has gradually shifted from family to the educational concept of the university and the influence of teachers and peers their cognition and recognition of the teaching industry come from their psychological potential and positive advantages even if they have a vague understanding of the teaching industry when filling out the college entrance examination they can also complete the internal behavior of teacher role recognition through psychological capital second professional commitment does not exhibit a regulatory effect on the path of the first half of the intermediary process demonstrating that the shaping of individuals by the family environment is primarily to enhance their psychological capital and cannot directly affect their love for their major however good psychological capital is still conducive to publicly funded normal students to develop the concept and behavior of teachers occupational identity conclusion the association between occupational identity and the family environment of publicly funded students at local normal colleges is multifaceted and complex through a survey of 395 chinese publicly funded normal students in seven local normal universities in sichuan province this research article examined the correlation among occupational identity psychological capital professional commitment and family environment the study findings indicate that the family environment plays a significant role in the professional identification of publicly funded normal school students as rural teachers although the family environment does not directly shape the occupational identity of publicly funded normal students who are about to return to rural areas in their hometowns conversely the proposed influence indirectly affects their career identification by stimulating their professional effect thereby reinforcing their belief in becoming a future rural teacher in addition to this the mediating role of psychological capital in the relationship between family environment and occupational identity as well as the moderating impact of professional commitment can support counselors and educators in devising intervention measures to enhance students occupational identity from this perspective the research findings of this article also hold important practical significance thus there is potential for much more to be done to help the students first educators students and parents should be aware that the family and school play a crucial role in promoting the professional identity of publicly funded normal students in particular students are prominently influenced by their families when choosing majors since students may have insufficient preparation to comprehend the possible challenges in the hardship areas there is a need to improve their rational and emotional understanding of rural education strengthen guidance on rural teacher career planning and assist them with explicit professional goals second it is essential to track the professional development of students for several years for dynamic monitoring of changes in professional identity accordingly normal universities may need to take more responsibility for professional commitment in the case of students families where parental support is insufficient while simultaneously encouraging their families to give them more emotional support finally the researchers of this study expect that this study will help future teachers who are about to commence their careers in difficult fields by better preparing them from the perspective of families and universities and giving them the confidence to become rural teachers limitations and future research direction owing to certain limitations the research findings of this study should be interpreted with caution first this article used crosssectional data therefore the causal relationship between variables cannot be accurately inferred from this study hence the adoption of time lag analysis and experimental methods can be considered in future research to perform a more profound discussion on the causal association between these variables second this study was carried out at normal universities in sichuan province within a specific context and the culture of china which may be different if carried out in other regions the countrys setting is a factor that considerably influences the results of a study while we consider the contextual factors the results may be more interesting if the influence of cultural values on such study variables were to be examined empirically data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation ethics statement ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements written informed consent from the patientsparticipants or patientsparticipants legal guardiannext of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

the occupational identity of local publicly funded students is associated with the stability of rural teachers to discuss the influence mechanisms of family environment psychological capital and professional commitment on occupational identity this study examined local publicly funded students with the occupational identity scale psychological capital scale professional commitment scale compiled and family environment scale in china we found no significant di erence in terms of sex source of birth only children or not and from teachers families or not junior students occupational identity was significantly higher than that of freshmen in addition we found that psychological capital plays a total mediation role between family environment and occupational identity psychological capital explains the influence of family environment on occupational identity while the moderating role of professional commitment on the family environment and psychological capital is not supported in this study it positively moderates the mediation role of psychological capital and occupational identity overall this study will be significant in improving the training quality of local publicly funded students

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i introduction infertility which hinders reproduction has always een a critical social issue in particular in a traditional society in which death rates were high and the society itself periodically suffered from acute population decrease this issue was a pro lem which imperiled a familys permanence and posed a threat to the existence of a community in most if not all past societies women were lamed for infertility such women were stigmati ed as eing defecti e and had to endure all kinds of social criticism and disad antages infertility was a huge pro lem in late medie al europe which had a high infant mortality rate hen women were una le to ha e a child their lord would take some of their inheritance some women e en recei ed a notification nullifying their marriage with their hus and which was a ery extreme decision muriel a jewish woman who li ed in england in was asked y her hus and da id to cancel her marriage she refused to do so and appealed to the court of jewish ra is howe er infertility could not e sol ed y harshly critici ing infertile women and imposing social sanctions on them his disaster had to e explained and re uired fundamental solutions although many societies iewed women as the cause of the pro lem approaches to the issue aried according to an indi idual societys characteristics hat were the typical medie al christian and european solutions medie al european churches were not unanimous in their interpretations and explanations of infertility during the he rew anti uity inexplica le infertility was generally considered to e a curse from god bologne on the other hand some early medie al churches taught that infertility was a trial to e orne stating that a long period of sterility could e a sign not of malediction ut of particular grace o taina le after repeated in the th century amon de i es a lord of barcelona confiscated all the property of a woman farmer who died without a child for the reason of her infertility at that time there was a contro ersy o er whether or not it is right for a woman with infertility to get married in the th century gratian argued that infertility was a fair reason for marriage nullity in addition according to christian doctrine when sexual intercourse is impossi le since men are frigid or impotent a di orce could e cancelled besides in the ninth century igmarus the arch ishop of eims said that when witches with the help of de ils pre ent married couples from ha ing sexual relations y using e il maleficium a di orce can e nullified prayer oren magidor but there existed the unreasona le perception that infertility was a curse from god while child earing was a lessing in addition it was widely elie ed that the de il and witchcraft caused infertility and sexual dysfunction e ans a famous preacher in the th century jean aulin said that the de il and witches impeded generation citing se en causes of infertility as shown in he malleus maleficarum a text from the th century some theologians and canonists elie ed that the de il could keep men and women from ha ing a child in arious ways and they often critici ed infertile women as witches kramer and sprenger e en in se enteenth century england samuel hieron suggested in his ook that arrenness was a form of punishment for sins on the contrary most educated doctors elie ed that infertility was triggered y different causes and that it was a treata le disease e en some clerics shared the reasona le elief that sterility was a sort of disease re uiring medical treatment and often argued for the possi ility of male infertility contradicting the common assumption that women were generally responsi le for infertility as discussed a o e there were conflicting opinions in medie al europe so it is ery difficult to pinpoint societys a erage perception of infertility in addition it is not easy to understand specifically what social criticisms and disad antages infertile women had to endure in medie al europe since there are almost no extant records it is ery rare that women in general in medie al europe kept records and especially so for those who were infertile his is e en the case for no le women ecause reading se en causes are for the glory of god for human humility for augmenting grace in marriage for saluting marriage excess of sex witchcraft we must riefly look at margheritas life she was orn in a no le family in lorence she married year old rancesco datini when she was years old in the year in a ignon rancesco was from rato near lorence and was a merchant who earned a great deal of money in usiness as a young man he reason why she a no le woman married a commoner was that her family were li ing in exile and were poor after ha ing een expelled from their hometown following her fathers execution owing to political strife in lorence she a mem er of the no le class pro ided her hus and youth and prestige and rancesco a ourgeois merchant ga e his wife a la ish lifestyle erhaps for this reason he did not recei e a dowry from his wifes family he datinis marriage was not always good margherita suffered from infertility which was a lifelong pro lem that haunted them his was a serious source of trou le and it worsened their con ugal relationship hile margheritas infertility is well known y some scholars its detailed history has remained under studied james her father who was in ol ed in political strife in lorence was con icted of treason and executed in by looking at the ways in which medical doctors diagnosed infertility and prescri ed treatments for it the issue can e understood in a more comprehensi e and alanced way e hope to reach a clear understanding of where the attitudes towards infertility held y ordinary people fell on the spectrum from the extremely unreasona le explanation of infertility as a religious malediction to the rational medical idea of infertility as a disease to e treated y medical practitioners ii social view of margheritas infertility it is known that in medie al european society christianity had an extremely road impact its reach extended to the infertility issue too because of the teaching be fruitful and multiply and replenish the earth in genesis fecundity was often understood as a lessing and con ersely infertility was thought of as a punishment or curse made y god although god used infertility as a punishment only once in the old estament lunenfeld and elder medie al churches preached that infertility was a punishment for sin or example homas a uinas descri ed infertility as e il and said that it is gods punishment he elie ed that the result of iolating the sacred compact of marriage was infertility and also thought that sacrilege and adultery etc caused infertility morice echen erria he same is often found in italian literature and artwork from the late middle ages hell and the last judgment ecame popular themes and infertility was depicted as eing related to sin because of this iewpoint the irgin marys wom was descri ed as a tool of redemption and infertility was descri ed as dia lerie some condemned infertility as the conduct of de ils or witches heologians interpreted infertility as the result of a wicked plan hatched y de ils in the th century hincmar arch ishop of eims said that witches with the help of de ils pre ented married couples from ha ing a child in the twelfth century gratian and eter the lom ard also put forth this iew ierre of alude a rench theologian who died in since jehoiakim incurred gods anger e en if he had sons they could not ecome a king under a curse heologians elie ed that it is possi le to make people not ha e a child through potion or incantation hincmar said that if a marriage has een annulled on account of the impotence of the hus and he cannot marry again if his impotence was due to natural causes if his condition howe er was the result of witchcraft and the marriage had een declared oid after the customary treatments had failed he was permitted to marry again eter the lom ard said that de his ui maleficiis impediti coire non possum contri uted to the association of infertility with satanism y listing fi e tricks done y de ils that hinder pregnancy kramer and sprenger baldwin irst since de ils ha e the a ility to pre ent odies from approaching each other de ils can make it so that men and women are not physically close to each other second de ils can stimulate sexual desire or free e it hird de ils can make men hate women y confusing mens imaginations ourth de ils can make men not get an erection ifth de ils can lock the flow of semen also many other theologians elie ed that using an e il spell could keep people from ha ing a child and critici ed the casting of such spells as a sin he perception of infertility as dia lerie was officially acknowledged y ope innocent iii who issued a papal ull in declaring that they hinder men from egetting and woman from concei ing and pre ent all consummation of marriage but the oices of the medie al churches were not unanimous in their iew of infertility some clerics who were familiar with medical knowledge interpreted infertility not in extremely religious terms ut in scientific or medical terms or instance al ertus magus a german dominican friar in the late thirteenth century who was known as a doctor explained the nature and causes of infertility as follows since there are many things which cause coitus there must e many circumstances promoting and impeding generation for whate er has a part in the causes also has a part in those causes circumstances which impede and promote operations he suggested that the impediment to generation may stem from the man rather than the woman cadden similarly john of mirfield a cleric in late fourteenth century england warned his readers of not only female ut also male infertility saying that when sterility happens 526 etween married people the males are accused y many people of not ha ing suita le seed since the perception and explanation of infertility y churches in the middle ages ranged from it eing a curse from god or a wicked act of the de il to it eing the result of oth female and male physical defects it is difficult to determine the common social perception and attitudes towards infertility e ask how ordinary people including margherita datini and her hus and comprehended and o ercame the pro lem of infertility rancescos relati es in his hometown and his usiness associates started to worry a out margheritas infertility after the couple had een married for se eral years and had not had a child hen the datinis were in a ignon the people who most often talked to rancesco a out margheritas infertility were monte angiolini and niccolo ecchini monte and rancesco seemed to ha e a relationship that went eyond ust eing usiness associates montes letters refer to rancesco and margherita as godfather and godmother herefore it seems that he was close enough to rancesco that they talked a out their pro lems in their letters their promise to ecome each others childrens godfather rancescos feeling of disappointment at ha ing no child and treatment for margheritas infertility etc were mentioned monte showed an acti e interest in the datinis infertility pro lem if he saw infertility as dia lerie that would not e the case in a letter dated april he expressed sorrow for margherita when telling the couple that his wife was pregnant in a letter dated e ruary he ga e che mon margherita non sia grossa mi pesa sono certo e lla sa ora che la sua e ostra comare e grossa credo si di presso a sei mesi scri ete a i olete io dira il atte i per noi essai penai mapure mi ra attemi al fatto rancesco wrote a letter to monte on january st and monte replied to the letter if he thought that infertility was a punishment which should e critici ed religiously and if he elie ed that margherita was a witch he would not ha e taken such an interest o monte this pro lem was a topic for casual con ersation and there was no fear regarding the issue in addition in a letter from octo er there was e en more intriguing content he wrote to rancesco lease tell margherita that we ha e done e erything we could to ecome a good godfather and a good godmother and we will continue to do it here y saying that they were doing their est to ecome a godfather and a godmother he was urging rancesco to try harder he pointed out that rancesco did not make as much effort as he did to ha e a child he datini usta codice cra monna ghostan a i scrisse per niccolo di bonarcorso e mando i per lui una scritta di mano di auolo dandrea come el gli e contento che ghaggi siano nel compito de denare do ere ritendre per monna ghostan a pero che la compra dice che non sentende compare case terre ma sscri ie o cose siano in ignone o ndel distretto ne fiol cccc che ac rancesco di marco non so se sono specificati e ghaggi e dela norio i li ro non gli date pero che nac la copia fece ser loren o buti ser bartelo apeno a la parte dele fanciulle e lla a scritto piu olte e cosi disse a niccolo i dicesse il tutto di loro rimettea in oi e cosi dice uole faciare di uanto edro sia a isogno a isar i dicio di tenpo in tenpo sil faro e di uanto sapero on manchera da isar i a monna margherita direte che io o fatto e fo mio potere effor ami che possiamo esse compari con effetto oi e io ma forse il molino e guasto per non a ere lac ua al modo usato ma forse uando sara ricostumato far frutto di uona farina e come fosse per fustare i lui diro ma non di meno fatene oi ostro potere e potea essere prima il ostro molino chel mio fara uona farina si che faccendo oi e noi nostro potedere tosto ci aura chagione da essere compari con effetto i dio pro edera il miglore come sta sempre lamed the hus and for the couples infertility in his letter of june he again lamed rancesco for his relati e la iness saying that he monte had done e erything possi le to make his own wife pregnant howe er in a letter dated octo er he lamed margherita for her la iness since she did not take any efforts to ha e a child unlike rancesco who tried ery hard to ha e a child howe er the fact that monte put some lame on rancesco is a sign that our notion that traditional society only lamed women for infertility may e a wrong one margheritas rother in law niccolo ecchini also offered rancesco many tips a out ha ing a child in a letter written july niccolo e en proposed that if margherita wanted he would lend her one of his own children in a letter written august he stated that his wife rancesca wanted to send one or two of her sons to her sister margherita in a letter written on e ruary he said he hoped that margherita would ha e a long waited child in a letter dated march he comforted rancesco who was disappointed at eing told so often that his wife was not pregnant la nostra comare o salutata per ostra parte io cercho coprato ella faccia ualche fanciullo del uale di nuo o siamp pu di fermo compari e per ancora non ci e i la ostra comare dicie oi prochacciate di fare de fanciulli che ella non nono elle piu fare e che sella per lasse a la comare consignerella come si fanno ma non cie il modo sal o uno ce oi costi prochacciate e noi ui prochacciaremo e chi prima lara si faccia come conponemo sella margherita ole dalla ranciescha un de suoi fanciulli per a iare e gli altri acomume ella ne contenda ma io orrei che lla ingrossasse e faciesse fanciulli che atendere laria di ua e piu mutia chati a a di i di uesto mese fecie la ranciescha uno fanciullo nella margheria non a ete oglia da ere figliuoli as shown in the letters etween the datinis and their relati es margheritas infertility seemed to e of great interest margheritas infertility and se ere cramps were casual con ersation topics not only her family and close relati es ut also usiness associates talked a out such things and they e en suggested many ways to treat them no ody denounced her as a witch or cursed the couple saying that they were eing punished y god his would not e the case if infertility was considered the result of sin and or was a ta oo topic another fact that can e confirmed from these letters is that at that time people elie ed that en ironmental and psychological factors play uite an important role in concei ing a child heir relati es in rato their hometown elie ed that it would pro ide a more suita le en ironment for the datinis to ha e a child than a ignon a faraway foreign land in mrs iera rancescos stepmother sent a letter to them telling them to come ack to their hometown of rato since they still did not ha e a child after se eral years of eing married ith gods grace you will e a le to ha e a child here god allowed you to ha e wealth there in a ignon here he will gi e you your family in a letter sent to them six months later she wrote if you come ack here the atmosphere will low away your trou les hat is ecause pleasure helps pregnancy ut trou les create an ad erse effect margheritas sister and her hus and ga e rancesco and margherita similar ad ice hey told the datinis that the land of rato is masculine and facilitates pregnancy hey also added that a couple who could not ha e a child in genoa had a child as soon as they mo ed to iii various ways of treating infertility he social perception of infertility can e confirmed in the ways in which it was treated just like there were many different perceptions on infertility there were a ariety of ways to treat it some treatments were full of religious madness some included traditional folk remedies and some used the medical knowledge a aila le at that time margherita and medicine in estern europe of the middle ages orrowed a lot from islamic medicine which inherited ancient greek and oman medical knowledge and de eloped it gynaecology in estern europe of the middle ages was no exception actually medical knowledge a out infertility in estern europe of the late medie al times was affected profoundly y medicine of ancient greek world and islamic world in the fifth century b c hippocrates a greek doctor analy ed many causes for infertility and presented prescription in the end of the second century soranus a doctor from the ni ersity of ephesus tried to co er most aspects of womens reproducti e pro lems including contraception and a ortion ut did not gi e detailed information to the matter of infertility galen suggested wom facilitation to examine infertility dioscorides thought that infertility could resulted from drug su stances and cited these su stances that cause infertility i n sina pointed out that infertility can also happen due to men as well as women he thought that infertility can e caused when there is something wrong with mens sperms or womens eggs in addition psychological factors can trigger infertility too in the th century a erroes addressed infertility in detail and diagnosed that if womens ody is too cold or too was full of professional doctors with degrees who wished for success after graduating from medical school some of them were from rural areas near lorence and they went to lorence which was at that time the ma or city in europe after earning their medical degrees to get o s hus the datinis could e treated y many doctors it was in the th century at the ni ersity of salerno that european medicine started to ha e an interest in infertility treatment in earnest at the ni ersity of salerno which was a leader in th century medie al european medicine most doctors and their medical texts dealt with infertility as a significant disease he rotula a typical medical ook concerning these issues which was translated into many languages after the th century when it was first written in latin stated that infertility was cura le through arious methods and mentioned physical and complexional features that were thought to cause infertility his medical ook presented certain physical features that were not conduci e to pregnancy efore suggesting prescriptions according to this text women who were too skinny or too fat or ha e wom s that were too hot or too humid would ha e difficulty getting pregnant moreo er it said that the wom could e too well lu ricated and thus could not accept sperm as for male infertility testicles that were too cold or too dry make it difficult to impregnate a woman in addition it said that when men lack heat sexual desire disappears and when men lack the desire to produce semen an erection does not happen is difficult for a woman to ha e a child when she is too fat or too weak when she has a complexion that is too hot or too cold when her wom is too lu ricated or when there is inflammation or leeding in the wom hen it comes to men a penis that is too ig or too small or is somehow defecti e makes pregnancy difficult he pointed out that an o erly hot or cold complexion creates an unsuita le temperature in a womens wom for ha ing a child and ad ised that if the temperature could e made normal pregnancy would e possi le herefore to ha e a child it was good to choose a spouse with the opposite humoral constitution to ones own and if a couple had married without knowing this it was thought to e much easier to change a womans humoral constitution than a mans interrogationes in cura sterilitatis a medical ook related to infertility which is thought to ha e een pu lished in the early th century also considered infertility as a medical disease his ook addressed issues related to the treatment of infertility it asked uestions related to womens humors and complexions physical features age marital status whether or not they had pre iously experienced pregnancy or miscarriage whether or not they had cramps the color of menstrual lood sexual experience and its fre uency and the color of sperm and its condition he reason why such arious uestions were asked was that the infertility treatment method differed for those with different complexions or humors cartelle and ingelmo it can e assumed from medical ooks such as rotula summa conser ationis et curationis and interrogationes in cura sterilitatis that the main causes of infertility at that time were thought to e humoral im alance and pro lems with complexion in this respect medical diagnosis and udgment of infertility were ased on humoral theory and complexional theory in the th century in london in a law suit seeking to cancel a marriage due to infertility the first thing that was checked was the couples humoral constitutions of course the prescriptions gi en for infertility were ased on humoral theory and complexional theory according to these theories when a womans wom was too humid medicine to dry out the wom was prescri ed and when a womans wom was too hot medicine to cool down the wom was prescri ed in the early th century montpellier medical school which had gained international fame in the infertility field considered infertility as a medical disease in the th century montpellier medical school irst da ids humors were checked and then muriels humors were checked hen pregnancy was possi le ut in the case of ha ing a miscarriage during pregnancy there were many cases in which oth medicine and talisman were used at that time in jewish and christian medical ooks using talisman together was suggested ractatus de sterilitate which is assumed to e written y an anonymous doctor from montpellier in the early th century enumerated internal and external causes of infertility according to this medical treatise on sterility the principal external cause was excessi e intake of cold food internal causes included physical characteristics or im alanced temperament like a ody that was too skinny or too fat too young an o erly wide or lu ricated uterus a undant menstruation suffocation and hernia of the wom sore mouth a lump on the wom etc he author discusses male infertility as well as female infertility e en while acknowledging that most of the causes stem from women cartelle he authors of this ook were not known for sure ut arnau de ilano a jordan de urre and aymond de moleriis were assumed to e the writers a doctor from italy in the th century oasted that his treatment methods were ery effecti e on many women with infertility stating i ha e seen this tried through true un uestiona le experience y many women who went without offspring for a long time one for years another for another for another for and another for and for all of these i pro ed this and found it to e true hen he explained a case of an approximately year old woman with infertility in detail according to his explanation this woman was ery fat and had a phlegmatic complexion so it was not easy for her to get pregnant ut thanks to his treatment she succeeded in ha ing a child it is not clear if infertility was really cured in that case ut there are many cases which can e used to argue that some treatments were effecti e benedetto eguardati da norcia a famous doctor in italy in the th century was known for treating the wife of rancesco sfor a the duke of milano he doctors who most often took care of margherita included loren o sassoni loren o di iero da rato naddino bo attieri and gio anni di banduccio of them naddino was the one who margherita and her green green howe er the author mentioned that some peoples infertility is caused y witchs spell and in this case only god can cure it e en though this ook mentioned infertility caused y spell asically it diagnosed infertility as a disease to cure loren o sassoni got his degree from the medical school of adua and taught students there although he tried to achie e fame as a doctor for financial pro lems he ga e up his dreams in his letter to datini of august he told that he ga e up teaching in hus and asked for the most ad ice on their infertility how did they conclude that it was not rancesco ut margherita who was responsi le for their childlessness in the later middle ages doctors could make a test to see whether the pro lem of infertility lies with the hus and wife or the couple ointly ha ing focused on female responsi ility the medical discussion of infertility egan to include male sterility in the later middle ages general methods used for infertility testing in the later middle ages were deri ed from hippocrates aristotle and a icenna one of the simplest tests was to pour male and female urine into a pot if there were worms in the pot ten days later the indi idual was considered sterile otherwise the indi idual was considered fertile howe er in the case of rancesco and margherita it seemed that it was not necessary to determine which one of them was infertile ecause rancesco already had a child efore their marriage in a ignon naddino a rato orn doctor mo ed to a ignon in the early s efore ecoming a famous physician who treated senior clerics and e entually ecame the opes doctor e en after mo ing to a ignon the medical school ith datinis introduction he could easily settle down in lorence relati ely he thought datini as a person like his father for him to trust and datini also treated him like his own son loren o often had a financial difficulty and orrowed money from datini datini always scolded loren o for his luxury and loren o defended himself a out it datini was willing to other himself to introduce loren o to many people datini often got prescription from loren o john of goddesdon a famous doctor of england said in his osa anglica written in the early fourteenth century that sterility is the failure to reproduce in a man and a woman so that in a man it may e said to e failure to act and produce a fetus and in a woman a failure to concei e a icenna gi es an explanation of the infertility test as follows if a man and woman complain of infertility and they want to know which one has the pro lem put oth sexual fluids in water and whiche er one floats the source of the pro lem is that person he continued to gi e medical ad ice to the datinis in a letter dated june naddino said that hot springs may help treat margheritas infertility haye in a letter dated e ruary he said that her infertility was caused y pain prior to menstruation he pro ided rancesco and margherita with a prescription saying that he had recently treated a patient with similar symptoms in a letter dated august he ga e hope to the couple saying that a woman who was suffering from a condition similar to that of margherita not only had experienced pain relief ut also went on to gi e irth to a son and a daughter howe er the prescription enclosed with the letter is not extant it seems that the datinis were recei ing help from arious doctors to treat infertility as datini naddino suggested in a letter to rancesco that margherita consult local doctors a out her infertility and take medication one of them was gio anni di bandocho in a letter dated august naddino said that replying to rancesco was delayed ecause information a out margheritas symptoms had een recei ed late from gio anni he characteristics of the seasons were considered in the prescriptions from oth gio anni and naddino naddino ad ised margherita to take the medicine in april or octo er cra haye he nature of the medications prescri ed y these doctors is not known ut they seemed to e inefficacious in addition margherita was more seriously ill than e er a letter from datini dated e ruary let naddino know that margherita was suffering pain prior to menstruation multiple ac uaintances who exchanged letters with datini testified that margherita was suffering se ere pain prior to menstruation in a letter dated april rancesco said that margherita was ery sick with pain that occurred efore menstruation efore in he prescriptions that the datinis recei ed from physicians to treat infertility ha e not een found howe er we can glean from their letters that doctors did not prescri e only one medicine to infertile women in fact doctors prescri ed multiple drugs that took into account a num er of physical characteristics including humor complexion and age rotula of salerno one of the female doctors also prescri ed medication in accordance with the humoral constitutions of infertile women if the uterus was too cold trifera magna was prescri ed his medicine seemed to e uite popular as an infertility drug in the late middle ages if the uterus was too humid theodoricon euporiston and paulinum were prescri ed spikenard which was the core component of theodoricon was considered to ha e ery dry and warm properties gal anum the main he rotula explains that the excessi e humidity of the wom suffocates the seed and the excessi e heat of the wom urns the semen rifera magna contained opium arious her s gums and spices it helps women concei e y purging the menses according to an anecdote in a medical ook written in the th century a priest in montpellier made a drug called trifera magna and a medicine mixed with santio uice to treat infertility many women ecame pregnant thanks to his medications and he gained greater fame than any doctors in montpellier hat santio was like was not disco ered rifera magna hese drugs were used to treat other diseases as well as infertility in this regard the core of infertility treatment was to make an infertile woman healthy enough so that she could ecome pregnant y impro ing any im alance in her humors margherita depended on folk remedies as well as doctors in a letter dated septem er margheritas sister rancesca said that many women there were pregnant including the wife of ommaso solderini thanks to a poultice made y the wife of nofri di messer lapo arnolfi rancesca e en seemed to ha e asked the wife of nofri di messer lapo arnolfi to make one she was told that this poultice which was effecti e in winter and was supposed to e applied to the stomach smelled so awful that margherita needed permission from rancesco to use it in a letter to her hus and dated septem er rancesca passed on this information to her hus and and also wrote that the poultice was made considering the health condition of each woman and that it did not cost ery much he letter did not mention what materials were used to make the poultice it is thought that nettle mandrake and artemisia which were widely used to make poultices for treating infertility were used morice one of the folkloric methods used y ordinary people in england was to apply wool soaked in asss milk to the womans na el or to ha e her athe and drink a potion cadden le li re des simples medecines says that spikenard is hot in the first degree and dry in the second degree and gal anum is hot in the third degree and moist in the first degree while a ula mentions that spikenard and gal anum are hot and dry in the third degree as illustrated y margheritas reliance on folk remedies people at the time were willing to go to any lengths to cure infertility he following anecdote illustrates this point according to a medical ook from th century rance there was a priest who cured infertility and made infertile women pregnant in montpellier he treated many infertile women using two drugs that he created and then gained greater fame than any other doctor in montpellier a num er of women reportedly came to him to get those two drugs and ecame pregnant margherita also went to hot springs for the purpose of treating infertility at the time people thought that hot springs are good for getting pregnant as they would help women reco er their strength in a letter dated may niccolo ecchini wrote that the datinis came ack healthy from the hot springs and he heard the encouraging news that margherita would e a le to e pregnant thanks to the hot springs in a letter dated june jacopo del nero di anni a medicine dealer said that the datinis came ack from the hot springs and he heard that margherita seemed to e pregnant howe er naddino wrote that a more careful approach was needed for the hot springs to e effecti e in a letter dated june he asked whether the hot springs were eneficial to datinis li er and margheritas infertility he said that hot springs may or may not ha e o dite che da alchimi enuti dal agno a ete sentito che ranciescho e lla margherita stanno ene piaciemi lo do na ia i ddio e llui priegho de fare gra ia di ritornare con uon punto e chon disposi ione da ere de figliuoli as datini usta codice letter from niccolò dellammannato to monte angiolini ranciescho nostro di poi tornato dal agno e gli sano e monna margherita grossa ieri giunse ui

while also relying on folk remedies religious therapies and e en magical remedies he comparati e analysis of datini documents medical ooks and theoretical treatises or prescripti e essays y clerics suggests that the general perception of infertility in medie al europe was located etween the extremely religious and modern medical conceptions of it

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introduction existing as an emerging topic in the field and undergoing constant evolution transcultural psychiatry addresses how social and cultural factors influence mental illness during the second half of the twentieth century phenomena such as globalization massive migrations and immigration occurring in ever increasing frequency continue to bring this topic to the forefront of discussion as challenges in the treatment of patients from varying cultural backgrounds emerge viewed from the biopsychosocial perspective culture delineates a framework for the evaluation of various expressions of emotion and behaviour as well as defining the limits of what counts as disorder as border restrictions are lifted cases which present with these particularities are bound to increase necessitating an increased attention to the influence that cultural and social factors play in the psychopathological clinical pictures which may present to the practitioner objectives the authors aim to briefly explore the concept of transcultural psychiatry and its importance in clinical presentation and practice with recourse to various clinical cases of international patients hospitalized in a portuguese psychiatry ward during a twoyear period methods a brief nonsystematized literature review was performed based on works most pertinent to the topic discussed as compliment to the topic a discussion of various clinical cases of hospitalized international patients is presented results culture has been demonstrated to contribute to psychopathological presentations in a variety of forms solidifying the old adage that no man is an island and giving reason to the biopsychosocial approach applied in clinical practice the impact of sociocultural factors is such that the dsm5tr includes in its classification culturespecific syndromes the cases discussed demonstrate the various nuances necessary not only in exploring psychopathology but also in implementing appropriate standards of care conclusions transcultural psychiatry rises as a relatively recent topic as well as raising important philosophical theoretical and technical challenges for mental health practitioners although existing as a subspecialty each mental health practitioner should strive to be transcultural taking into consideration the influence that these factors exert on mental illness the patient should be evaluated with consideration to their cultural background as well as not neglecting how the culture of the practitioner may influence the interpretation of psychopathological presentation introduction mental illness is characterized by a major emotional cognitive and or behavioral impairment of an individual it is usually accompanied by distress or functional impairments in important areas mental illness affects 489 of the moroccan population this makes it a major public health issue but one that is still unrecognized and underestimated in the general population because of certain cultural aspects considering mental illness as a taboo or privileging traditional healing objectives to evaluate the time between the initial symptomatology and the first psychiatric consultation identify the course of action to be taken in the face of the first symptoms of the illness determine the factors responsible for the diagnostic delay methods we conducted a crosssectional study to assess the duration between initial symptoms and diagnosis and to identify the responsible factors of diagnostic delay this study included 200 patients followed at the psychiatry department of the university hospital arrazi of salé and evaluated by an hetero questionnaire results the average age of our patients was 29 years male gender was predominant the mean diagnostic delay was 46 months data analysis showed some significant results the diagnostic delay was longer in male patients the diagnsotic delay conditioned response to treatment and therefore the prognosis conclusions in conclusion public awareness of psychiatric problems treatment availability and educational efforts to overcome the social stigma are essential to reduce diagnostic delay and improve the prognosis of schizophrenia disclosure of disclosure of interest none declared epv0403 migration perceived discrimination and the development of psychosis v barata j bastos c cativo and p gonçalves introduction migration is a rapidly growing phenomenon in european countries and its association with psychotic disorders is a public health concern psychosis is more prevalent among migrants which suggests that adverse social experiences play an important role in its pathogenesis throughout the migration process migrants are exposed to several social disadvantages including in the postimmigration context where perceived discrimination appears to be an important stressor in fact the highest incidence rates of psychosis occur in the most discriminated populations namely migrants with darker skin complexion particularly when living in lowethnicdensity neighborhoods where both discrimination and social isolation are more prominent objectives to conduct an updated review about the association between migration perceived discrimination and psychosis aiming to better understand the mechanisms involved methods narrative literature review using the keywords migration psychosis discrimination racism on pubmed database in conjunction with presentation of a clinical case concerning a patient from guineabissau admitted to our hospital in the context of firstepisode psychosis with onset months after completing the mediterranean migration route to europe results literature suggests that experiences of racism and social exclusion contribute to feelings of imminent danger fear and general anxiety which may develop into paranoid ideas of ubiquitous persecution furthermore intense social defeat experiences common in migrants are associated with more distressing forms of delusional content with delusions of psychological persecution being more common however there is also evidence that migrants with fep have better occupational and social functioning profiles compared to natives suggesting that in these patients there is a higher burden of socialenvironmental risk factors with the onset of psychosis occurring only when this burden overcomes a higher threshold our patient fits this description after completing his migratory route and while living in an italian refugee camp he described suffering experiences of severe discrimination real or not these experiences escalated to become delusional ideas of persecution involving european governments thought to seek for his humiliation despite the presence of psychotic symptoms this patient was able to maintain a reasonable level of functioning during years up to his psychiatric admission conclusions given the notorious effect of perceived discrimination and racism on the increased risk of psychosis in immigrants it is urgent to adopt policies that promote the social protection of these vulnerable groups namely through enhancing their integration in the host countries a mercadorodríguez1 c martín requena 1 a cano baena 1 i zorrilla martínez 1234 a gonzálezpinto arrillaga 1345 and l marbarrutia 1 introduction major depressive disorder is a mental health disorder characterised by persistently low mood anhedonia feelings of worthlessness and guilt altered appetite weight and sleep and suicidal ideation about onethird of patients do not respond to available antidepressants treatmentresistant depression is a clinical term used to define a lack of response to two or more ad in patients with mdd that do not respond to other lines of treatment either trd is associated with an increased risk of relapse hospitalisation and suicide esketamine is a noncompetitive nmdar antagonist that acts as an antidepressant by modulating glutamatergic neurotransmission disturbed in mdd patients it has recently been approved by the european commission as a fastacting nasal spray therapy for depression and suicidal ideation after showing effectiveness in trd patients objectives the aim of this study is to determine the effectiveness safety and tolerability of intranasal esketamine in two trddiagnosed patients and to assess their clinical evolution methods a prospective study was conducted describing the evolution of two trd patients treated with intranasal esketamine we used the hamilton depression rating scale to quantify the severity of their symptoms and assess their recovery over time analyzing the score change from baseline to endpoint as a primary outcome of the study we also applied the addensbrooke cognitive examination as a tool to establish their cognitive condition before therapy and its evolution changes in dosage during treatment adverse effects time required for onset of action clinical outcomes and other variables were also measured results intranasal esketamine was administered twice a week during the first 4week induction phase and weekly during the following 6month maintenance phase dosage of antidepressant was determined depending on each patients age and clinical evolution being 56 mg the initial dose for case 1 and 28 mg for case 2 this antidepressant was effective in both patients in a fastacting way with the onset of action occuring within the first two weeks during the course of treatment the hdrs score significantly decreased associated with improvement and remission of depressive symptoms cognitive performance got better in both cases none of the patients discontinued treatment due to adverse effects or lack of efficacy conclusions our data suggest that intranasal esketamine therapy is a good alternative in trd patients being effective fastacting and welltolerated with a manageable safety profile clinical stability was also observed in the mediumterm followup after the end of treatment this presents esketamine as a promising therapeutic and effective strategy in mdd patients who are either treatmentresistant or acutely suicidal disclosure of interest none declared

and language probably unconsciously influence how the medical team treats this patients case cultural social factors persistently present as barriers in clinical practice conclusions race language barriers and mental health diagnoses as well as other intersectional factors do have a great impact in the treatment patients receive there is yet a lot to do when it comes to educating health professionals if we want to offer the best medical assistance

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introduction much of the world lacks sufficient healthcare and has high rates of infant and maternal mortality one strategy for increasing access to care in servicelimited regions is to introduce community health worker programs 1 chws are typically selected from the communities they will serve and receive limited training they have the goals of extending services but also of using their knowledge of local customs to help deliver more effective messaging increase demand for key services and facilitate behavior change 1 indeed evaluations of chw programs demonstrate that they are highly effective at promoting increased uptake of certain behaviors 23 however some evaluations also find that some chw programs are underperforming with respect to achieving certain levels of uptake in their beneficiary communities or argue for improvements in knowledge or particular skills 4 in this paper we focus on the largest chw program in the world the asha program which was founded by the government of indias national rural health mission in 2005 56 the program started in the highestneed states of india in 2006 and gradually increased in scope now serving nearly the entire country with over 1 million workers in describing the asha role the nrhm states that every village large habitat will have a female accredited social health activist to act as the interface between the community and the public health system as such ashas often act as a bridge as they are tasked with connecting local beneficiaries to the formal health system with the goal of improving maternal and newborn health outcomes 7 at least in rationale ashas are meant to facilitate behavior change but this aspect of their role has arguably been deemphasized andor overshadowed in favor of service extension 89 the asha program has focused on behaviors especially relevant to reproductive maternal newborn and child health such as institutional delivery the consumption of ironfolic acid tablets and antenatal and postnatal care visits the goals of increasing uptake of such behaviors are to lower the high rates of maternal and infant mortality and morbidity that prevails in much of india particularly in rural and hardtoreach areas for instance bihar where the present study takes place had the lowest per capita gross domestic state product in india in 2015 along with the lowest literacy rate and lowest real per capita revenue expenditure on health 10 bihar also has high levels of underfive mortality infant mortality and maternal mortality 10 all of which are higher than the averages across india and are of major concern from a global public health perspective motivated by indicators like these considerable effort has gone into the development of public health initiatives and chw programs in bihar and across india as with other chw programs there are many indications that health outcomes have improved as a function of ashamother interaction especially if those interactions occur early and often 11 for example smittenaar et al 11 found several connections between asha presence or assistance and greater uptake of recommended health behaviors by recent mothers in uttar pradesh india a recent study by agarwal et al 5 found that asha interactions lead to increases in anc checkups institutional deliveries and use of a skilled birth attendant they also found that in areas where ashas were highly active that women of the lowest castes and from the poorest households had higher odds of receiving asha services other studies however have questioned the efficacy of ashas lyngdoh et al 12 found that interactions with chws in india including ashas did not lead to increased knowledge about important aspects of perinatal health care in a study focused on incentives koehn et al 13 looked at four states in india and found that mothers were sometimes less likely to have adopted a recommended health behavior if they were visited by an asha rather than by an anganwadi worker scott et al 14 conducted an extensive literature review of 10 years of published research evaluating the asha program in studies about routine asha performance the majority of the reviewed papers found mixed or negative results negative 23 less than 25 were positive indeed when looking across the full range of studies of asha performance it is easy to form the somewhat contradictory impression that ashas are at once highly effective and not effective at all one shortcoming of asha evaluations is that many different metrics are used by different studies for instance across the studies summarized in scott et al 14 asha efficacy was defined differently based on the focus of each study and included knowledge appraisals opinions stated by mothers selfreports by ashas the frequency of asha contacts with mothers and calculated effects of ashas on the uptake of one to several possible health behaviors among other measures thus across these studies there was a wide range of definitions of efficacy because of such wide variation in how performance is evaluated it is difficult to make general conclusions about asha performance or to identify which specific aspects of the asha role impact maternal health and behavior and why 1114 another issue with studies of asha efficacy is the lack of comparative reference many studies describe an ashas effect as positive mixed or negative without considering the associated question of effective or ineffective compared to whatwhom for this reason we consider asha efficacy compared to nine other possible health influencers who are known to convey healthrelevant information in bihar 1516 motivated by the inconsistent impression of asha performance due to the prevalence of mixed or negative evaluations and by the calls for more data on the matter we analyze perinatal health data from 1166 recent mothers from bihar india we define efficacy as the statistical effect of ashas on the uptake of biomedicallyrecommended health behaviors while acknowledging that efficacy can be captured with various possible metrics 14 we look at efficacy across a range of nine potential sources of influence and 12 different perinatalhealth behaviors and how they align with the biomedical recommendations that are intended to flow from the medical system to the community via chws finally if service or performance gaps are found it is important to consider potential barriers and offer a reasonable diagnosis of what is constraining the service for this reason we evaluate the possibility that differences between ashas and mothers due to caste religion or wealth affect the reach of services the data analyzed here are part of project rise a mixedmethods research program aimed at understanding the many factors that influence how an asha affects maternal and newborn health in bihar india here we focus on the subset of our data that speaks to asha efficacy and health behavior research questions given recent interest on the topic of asha efficacy 56 the general importance of chws as a potential agent of healthimproving behavior 12 and the impression from the literature that ashas have mixed or even negative effects on health behavior 14 we address the following questions q1 what is the statistical effect of ashas on the uptake of recommended perinatal behaviors q2 how does asha influence vary across behaviors and how does it compare to other sources of influence q3 do caste religion or wealth act as barriers to effective service delivery to answer these research questions we describe ashamother contacts across a range of perinatal behaviors quantify asha efficacy compared to other sources of influence and consider possible barriers to that influence materials and methods participant sampling and recruitment project rise investigators recruited and interviewed participants during a threemonth period from june to august 2019 bihar has three major language groups magahi maithili and bhojpuri the region where maithili is spoken covers a much larger area of bihar than the other two for this reason one district was sampled from the regions where magahi and bhojpuri are spoken and two were sampled from the region where maithili is spoken within each of these four districts two blocks were randomly sampled and from within each of the eight selected blocks 50 anganwadi centers were randomly sampled awcs were the focal sampling unit because these represent the catchment areas for ashas three recent mothers were randomly recruited from each of these 400 awcs based on asha registers thirtyfour surveys were excluded for being incomplete or for falling outside of the recruitment criteria for the survey resulting in a final sample size of 1166 all of the mothers recruited had given birth within the previous six months to maximize memory of behaviors undertaken during the perinatal period before interviewing the sample of mothers we conducted focus group discussions with recent mothers and mothersinlaw in order to gain a wider qualitative understanding of perinatal behavior and belief we also conducted oneonone interviews with ashas and other local influencers these qualitative discussions provided valuable insights for the project and were also used to design the questionnaire in the fgds we learned about many behaviors that are not usually the focus of health initiatives but were often referred to by the women who participated in the discussions the fgds informed the selection of behaviors in this study the consent included a brief description of the survey description of the role of the respondent in the study including the expected duration of the respondent s participation clear indication that participation is voluntary and that the information provided would be confidential consent was obtained verbally by each interviewer and recorded as a response on the form ethics statement coding focal behaviors our extensive survey effort included questions about the uptake of perinatal behaviors the type and nature of contact and services that ashas assisted mothers in obtaining and about other factors related to perinatal decisions and behaviors some of these questions lead readily to a binary yesno response and others required coding for example one question asks about the month that anc registration occurred for the analysis below this is considered a question about timely anc registration and as such if the response is 3 months or less it is coded as a yes and if it is 4 months or longer it is coded as a no as such it is important to keep in mind that results in the not recommended direction for anc registration indicate late registration more often than not registering at all another question asks about treating the umbilical cord stump with a substance after delivery the question has many options for locallyused substances but here we distill these responses to treated the cord stump with something or did not treat the cord stump table 1 provides a definition for each of the 12 focal behaviors three general types of behavior are included in table 1 one group consists of perinatal health behaviors typically associated with the asha program that are directly incentivized anc registration anc checkups and institutional delivery a second group includes behaviors that are indirectly incentivized consuming 100 or more ifa tablets during pregnancy colostrum feeding timely initiation of breastfeeding care of the cordstump and not bathing the newborn within 24 hours the difference between directly and indirectly incentivized is whether or not the asha receives a payment specifically for completing that discrete task indirectly incentivized tasks are linked to messaging and counseling duties that the asha has and therefore do not lead to payment on a percompletion basis for instance the asha is meant to relay information that encourages taking ifa tablets and feeding colostrum but she does not receive a separate payment for each woman who feeds colostrum to her newborn nor does she complete paperwork registering that a woman in her catchment selfreports feeding her newborn the colostrum ifa tablets are indirectly incentivized based on the asha distributing the target amount but not on what individual mothers report actually consuming them the third group of behaviors evaluated are not incentivized nor typically associated with the asha program these behaviors were identified during our qualitative interviews and included concealing the pregnancy fasting during pregnancy doing heavy work during pregnancy and avoiding cerealbased foods in the first week postpartum these were mentioned during focus group discussions with mothers and mothersinlaw and then added to our quantitative survey for exploratory purposes we found that many women spontaneously associated advice on these behaviors with local influencers including ashas concealing pregnancy particularly early pregnancy is an extremely common behavior practiced in most cultures of the world here it is coded as not recommended because it can result in delays in anc registration and the initiation of other perinatal health behaviors 17 such as the start of taking ifa tablets in this sense we are not implying that pregnant women should disclose their new pregnancies to the general public by any given time but rather that a default biomedical recommendation in this setting would be that mothers disclose a pregnancy to relevant health officials especially the asha as early in the pregnancy as possible because this facilitates earlier anc registration and may increase the probability of taking the full recommended dosage of ifa we also found that many women reported fasting during their pregnancy either regularly or for festivals from a biomedical perspective food limitation during pregnancy is not recommended especially as women in bihar are commonly undernourished at the start of pregnancy 1819 we also included mothers avoiding cerealbased foods postpartum as a behavior that is not biomedically recommended with the same reasoning that the caloric demands of breastfeeding call for an increase in food intake and as such food restrictions in a foodlimited context should be avoided when the body is producing breastmilk moreover cereals are the most dominant food group consumed by women in bihar where dietary diversity tends to be low 19 and where there are many existing social conventions that delay or prevent women from eating 20 the avoidance of cereals is related to a commonly practiced postnatal ritual called chhathi which occurs on the sixth day after birth some versions of chhathi call for avoiding cereals between delivery and the occasion on the sixth day after birth this third group of behaviors provides interesting reference points for the range of behaviors that mothers in this sample reported as relevant to their perinatal experiences and that they associated with various local healthrelevant influencers each of the behaviors in table 1 is analyzed with respect to biomedical recommendations for some behaviors the recommendation is to do the behavior and in these cases yes is the recommended response for others the recommendation is to not do the behavior and no is the recommended response for the analysis below these latter cases where no is the recommended response are reverse coded such that the question is did the participant do the recommended behavior influencers while the asha is the focus of our analysis in this study it is important to note that ashas are one of many possible influencers who can lead to healthrelevant decisionmaking within indias chw workforce there are two main categories of chws namely ashas and auxiliary nurse midwives with extended support of awws through the integrated child development services system across these chws ashas anms and awws each have distinct but complementary responsibilities ashas were meant to be health promoters activists and counselors ashas are also the first points of contact for linking the beneficiaries to appropriate health services while the aww and asha have distinct roles there are also many overlaps related to maternal and child health and nutrition in addition to these other chws family members friends traditional birth attendants and others can influence maternal decision making 21 most of these sources and their interrelationships have not been widely studied nor compared specifically to asha influence for these reasons each of the behaviors in table 1 can be influenced by nine possible sources these sources of influence for each behavior are described in table 2 during the survey each participant is asked about the sources of influence regardless of the response that is we ask participants who the sources of influence were for those who had a hospital delivery as well as those who did not for each of these behaviors participants spontaneously mentioned the sources of influence which were recorded to a list of likely options that had been prepopulated using data collection tablets this aspect of the survey design is important to keep in mind in light of the results below because participants were not directly asked something akin to did the asha influence your decision about this behavior rather they were asked who influenced you to do this to which respondents named sources of influence spontaneously and without prompting hence mentions of the asha in association with behaviors that are incentivized and very clearly part of the program as well as those that are not typically associated with the asha can reveal the salience of the ashas association with a range of behaviors and the observed mentions are not a function of being primed by the survey question analysis procedure for question one we measure the asha effect on maternal behaviors with two approaches for the first the response variable is a maternal health score that captures the uptake of recommended behaviors by mothers we examine the relationship between this health score and an asha interaction score that captures ashamother interaction as a sum of all visits and services provided that were captured in our dataset the maternal health score is a simple count of the number of health behaviors each mother reports adopting of the 12 in table 1 in some cases the recommendation is to do a behavior and in other cases the recommendation is to not do a behavior for this reason we code all questions as a 1 if the response is consistent with the biomedical recommendation and a 0 if it is inconsistent the asha interaction score is a sum of all specific named interactions and services associated with ashas this includes the number of household visits made by trimester the number of postpartum visits and the number of services associated with ashas a list of the items from the questionnaire that contributes to this score and the number responding in the affirmative is in som we investigated the correlation between these two measures with a regression model where the maternal health score was the response variable this was first modeled as a poisson distribution because the response is a count variable but significant underdispersion was detected we then compared fits of a negative binomial a quasipoisson and a mean parametrized conwaymaxwell poisson by aicc the mpcmp had the lowest aicc value and was used in the results below the coefficients were identical across all four models the choice of error distribution affected only the standard error the second analysis used to address q1 uses a measure of asha effect based on the followup questions about influence this the response variable is binary indicating a yesno for whether or not each response was aligned with the biomedical recommendation for each behavior we used logistic regressions to estimate odds ratios that women report adopting a recommended behavior given the source of influence associated with it the control variables in this regression are age age at marriage parity education wealth to compute an individual wealth score we used a 36item inventory that includes questions about possessions and household characteristics the resulting wealth measure are based on a principle component analysis for question 2 we again use a binary response variable for the uptake of recommended biomedical practices but we also include interactions between each influencer and behavior we then use a model selection algorithm to remove irrelevant interactions the model selection process worked as follows we start with a saturated model that includes all possible behavior by influencer interactions and then use a backward model selection procedure 24 to sequentially drop interactions to optimize model performance measured by aicc 25 interactions that do not minimize aicc are dropped from the model this sequential dropping of irrelevant interactions eventually results in the most parsimonious model using aicc as a criterion for excluding terms helps discourage overfitting which is desirable because increasing the number of parameters in the model almost always improves the goodness of the fit the final selected model is then used to estimate predicted probabilities that mothers engage in each behavior by using predicted probabilities computed from the final model we include all retained interactions as well as controls in the estimated probabilities controls were included in addition to the categorical variable for each question and a dummy variable for each influencer participants could report multiple influencers for each question to validate the final selected model we calculated variance inflation factors using the r package car 26 if individual variables have large effects inflating the variance of the model then they may be problematically correlated with other variables in the model we examined the final model for vifs and sequentially removed interactions with the highest vif until all were below 50 all analysis was conducted with the r opensource computing software 27 for question 3 we conduct a moderation analysis to evaluate if caste religion or wealth affect asha service delivery using a separate model for each possible moderator moderation analysis tests for the possibility that a relationship between two variables is modified by a third we ask if caste religion or wealth moderate the relationship between maternal health score and asha interaction to do this we added interaction terms to each potential moderator resulting in three separate models one for each possible moderator differences in religion and caste were coded as binary variables where 1 indicates asha and mother are from the same caste or religion and 0 means different caste or religion wealth difference is a continuous measure based on subtracting the wealth score of the mother from the wealth score of the asha in fitting these models significant underdispersion was also detected and we again fit mpcmp generalized linear models using the r package mpcmp 22 the test for moderation is based on a significant interaction between each moderator and the asha interaction score both the interaction and the main effect must be considered to understand the result of the moderation we use a graphical approach to do this results composite scores for asha interaction and maternal health the analysis for q1 and q3 considers two scores that are composites of variables recorded in our survey of recent mothers the asha interaction score and the maternal health score both are count variables the asha interaction score is a tally of all asha interactions and serviceassociated references and the maternal health score is a count of each of the behaviors in table 1 that is done according to biomedical recommendations summing the responses that compose the asha interaction score yielded an integer value that varies from zero to 74 with a median of 9 the largest three values 74 and two at 60 are extreme values reported by women who ashas visited 20 and 30 times in the second and third trimesters these unusually frequent visits occurred because these women lived next door to an asha they were excluded from the analysis below the maternal health score is a count of each behavior that the mothers report having practiced according to biomedical recommendations during her last pregnancy the maximum possible value for this measure is 12 one for each behavior in table 1 the mean was 635 and the median was 70 density plots for each measure are in fig 1 independent variables and descriptives descriptive statistics for the control variables are listed in table 3 all variables are categorical so we report the counts and percentages of samples in each category across the control we also describe the nature and frequency of ashamother interactions to provide a more finegrained breakdown of the asha interaction score for instance the number of home visits during pregnancy was highly variable many mothers did not receive a single home visit for the duration of a trimester of the women surveyed 253 did not receive an asha visit during pregnancy the number of women going a full trimester without an asha visit decreases from the first to the third trimesters another question on the survey asked about postnatal care visits during the first week after birth of the women surveyed 615 did not receive a postpartum home visit in the first week after birth the survey also asked mothers about visits with the asha outside of the home or if the asha sends her messages through a family member we found that 46 of recent mothers said they had a healthrelated visit with an asha outside of their home and 39 said they received healthrelated advice that an asha delivered to them via a close relative moreover 23 said yes to both of these questions these alternative routes may be an important method for asha messaging of the mothers who did not receive a home visit during pregnancy 77 met with the asha outside of their homes leaving 176 with no direct asha contact during pregnancy lastly we also ask mothers if they received healthrelated messages from their asha that was sent through a family member of which 457 did however there were still 154 recent mothers who did not receive a home visit did not meet with an asha outside of their homes nor receive health messaging from the asah via a family member some evaluations of maternal health behavior look at bundles of actions that fit together for instance kumar et al 28 define the full anc as 100 or more ifa doses at least one tetanus injection and four or more anc checkups while tetanus injection is not a focal behavior of this study we asked mothers about receiving an injection in our survey and can compare the percent of mothers in our sample who got the full anc to the results of kumar et al in short our results are very similar we find that about 23 of mothers reported adopting all three of these behaviors while they found 21 moreover the percentages adopting each component of the full anc are very similar in our sample from bihar and the national averages in kumar et al 28 q1 what is the statistical effect of ashas on the uptake of recommended perinatal behaviors as described in the methods we fit two statistical models to assess q1 the first uses a measure of asha interaction and we fit a mpcmp model to assess the relationship between maternal health score and asha interaction score increased interaction with ashas was associated with the uptake of more recommended perinatal health behaviors such that each additional interaction increases the maternal health score by about 2 across the range of asha interaction score there is wide variation in uptake and many women have very low scores the second model used to assess q1 consists of a binary response variable with controls for age wealth education and parity along with dummy variables for each source of influence fig 3 shows that ashas have the largest positive effect on the overall uptake of health behaviors among the influencers considered here the only influencer with an overall effect on the uptake of recommended behaviors that is lower than the reference category of no one is the rmp meaning that if an rmp was named as an influencer mothers were roughly 50 less likely to have taken up biomedicallyrecommended behaviors than if they named no one all other influencers are positive or neutral but note that the selection of no one as a source of influence seems to have been particularly common among women who did q2 how does asha influence vary across behaviors and how does it compare to other sources of influence to infer which influencers had the strongest effects on changing the probability that mothers engaged with each recommended behavior we report modelpredicted probabilities that mothers adopt each recommended behavior given each source of influence accounting for controls and the most parsimonious set of interactions between influencers and behaviors fig modelpredicted probabilities of doing the recommended behavior for each combination of influencer and behavior questions where the recommendation is to not do a behavior have been recoded such that a response of 1 always means consistent with biomedical recommendations behaviors are listed roughly sequentially from top to bottom on the yaxis influencers are ordered by the average magnitude of effect from left to right on the yaxis such that more strongly positive sources of influence are to the left see som for full results of the underlying regression behavior by behavior the asha is consistently among the influencers with the highest positive effect on the probability that recent mothers are engaging in recommended health behaviors for instance ashas have the strongest positive effect on the probability that mothers had an institutional delivery and early anc registration for fasting while pregnant and working while pregnant the asha was second and third respectively many women did not receive a home visit in the first week postpartum but the asha has a strong positive effect on behaviors during that time the ashas effect is relatively strong and positive for directly and indirectly incentivized behaviors as well as those that are not incentivized the predicted probability that a mother completes a full ifa regimen is seemingly low if she names an asha as an influencer at just 43 but that is the secondhighest value across influencers for that behavior and ifa completion may be limited by supply issues that are out of the ashas control fig 4 gives the modelpredicted probabilities of doing the recommended behavior for each influencer category we can also use the selected model to calculate inferential statistics for which influencers are raising or lowering the probabilities we estimate the effect of each influencer by behavior during pregnancy and postpartum the panels in these two figures identify the magnitude each influencer has the probability of doing the recommended behavior relative to all other sources of influence the thin black horizontal dotted line indicates the reference level of no one the numbers in italics for each category on the xaxis give the number of times that influencer was named for that behavior for example the upper right panel of fig 6 shows anc registration and 521 women named the asha as an influencer for this behavior 366 named family 200 named friendsrelativesneighbors this is useful for identifying cases where rarely mentioned influencers are having large effects on the predicted probability or when commonly named influencers have intermediate effects for instance the media have a large positive statistical effect for not applying substances to the cord stump as recommended but the media was mentioned just six times in association with this behavior across the behaviors considered here the asha is consistently nudging behavior in the biomedicallydesirable direction and her effect is always more positive than sources of normative influence like family or friendsrelativesneighbors her effect is typically near the formal health care providers and sometimes even larger in magnitude we see clear evidence that she is having positive effects on behaviors of biomedical relevance that are not formally associated with the asha role q3 do caste religion or wealth act as barriers to effective service delivery to address q3 we conducted a moderation analysis to see if the influence of asha interaction on the number of health behaviors adopted by mothers was moderated by ashamother differences we considered differences by caste religion and wealth none of these differences removed the strong positive effect that asha interaction has on the number of health behaviors adopted but the interaction between caste and asha interaction score was significant and the interaction with religion was nearly so however the main effect of caste difference was slightly positive and the interaction was slightly negative yielding a total effect of caste difference not being a major impediment to ashamother contacts grey bars are effects similar to no one blue bars are negative effects meaning the influencer lowers the probability that the woman practices the recommended behavior compared to the reference category of no one the thin black dashed line is drawn at the predicted probability of the reference category no one to better visualize the moderating effects of religion and caste we plot the predicted effects of each this shows that the effects of each are indeed very minor and do not likely account for the barrier that prevents some mothers from receiving home visits during pregnancy for caste the effect is such that when an asha and mother castes are different the maternal health score raises more steeply with asha interaction than when they are the same for religious differences there is not an appreciable effect we conducted some exploratory supplementary analysis to further evaluate if differences between ashas and mothers in caste religion or wealth could be factors that limit asha efficacy or reach in these we identified an at risk group of women as those who did not receive any home visits during pregnancy from the asha we used the same set of controls and fit a binomial logistic regression in an attempt to identify factors that might predict membership in this atrisk group the results suggest that caste differences actually reduce the risk of not receiving a visit and wealth differences may slightly increase the risk of being in this group although the cis do encompass 10 however these results are sensitive to how the risk group is defined and do not paint a clear picture for the role of these differences in affecting those women who receive the fewest asha contacts for instance the effects become neutral if we define the risk group as women who did not receive a home visit and did not receive a visit from the asha outside of the home the details of these analyses are in the som in this analysis the signal of such differences was either very mild or not detectable and other factors should also be considered when evaluating the observation that some mothers did not receive home visits discussion ashas are highly effective at increasing uptake in 12 healthpromoting behaviors our results indicate strong positive correlations between the uptake of recommended behaviors by mothers and either having contact with ashas or being influenced by them mothers who named ashas as a source of influence were more than six times more likely to adopt a recommended behavior than those who named no one when individual behaviors are examined ashas have a strong positive association with all 12 focal behaviors and have effects similar in magnitude to formal medical staff and sometimes exceeding them ashas also have strong positive associations with behaviors that occur early postpartum even though many women did not receive a home visit in the first week after birth furthermore ashas have relatively strong influences on behaviors that are directly incentivized indirectly incentivized and even those that are nonincentivized we also investigated the possibility that asha contacts were moderated by differences between ashas and mothers in caste religion or wealth while we did find some small moderating effects the picture in fig 7 implies that such differences are not responsible for the lack of asha reach to some households that said caste dynamics in rural bihar have many effects on daily life and the analysis here should be interpreted cautiously and not taken as an indicator that caste differences do not affect health system access several lines of evidence suggest that ashas are highly salient in the minds of bihari mothers across a broad spectrum of healthrelevant behaviors the regression for the overall effect of ashas on recommended health behavior represents a highly general emergent positive association with uptake across 12 different behaviors the mentions of the asha by recent mothers in association with each of these behaviors is spontaneous they are asked only about the general source of influence not provided with a list of options this general salience is similar to the regressions that capture the effect of asha interaction on maternal health score but using a different measure based on a count of actual ashanamed interactions and services provided these effects are different from finding a specific relation between a type of visit and a single outcome which are more commonly the focus in evaluations of asha performance together they speak to a pervasive and highly general asha effect in the community high asha efficacy is coupled with limitations in reach the descriptions of ashamother contacts make it clear that this general efficacy does not have a sufficiently broad reach however asha guidelines do not specify a target number of visits during pregnancy but they do stipulate that visits should occur a recent analysis of asha performance in uttar pradesh by smittenaar et al 11 suggested that ashas should visit an expectant mother as soon as possible after learning she is pregnant and 46 times over the course of the pregnancy this suggestion seems reasonable and if taken as a target a median number of visits would require an increase of 1 to 3 visits per pregnancy in this sample distinguishing ashas from the asha program to disentangle the factors that might lead to high efficacy on the one hand and insufficient reach on the other we think it is important to distinguish between the ashaasperson and the asha program as individuals ashas have high efficacy but efficacy could be better leveraged or enhanced with support and training from the program in other words conditional upon visiting the mothers or otherwise reaching them with messaging the ashas are highly effective perhaps improvements could be made at the program level that find ways to increase the workforce manage the workload or remove barriers from underserviced households this needs to be kept in mind when discussing a need for ashas to increase home visits or other issues that also effectively increase demands on her time travel requirements and the like as a program there may be certain factors that limit or constrain the asha workforce for instance transportation is a commonly mentioned difficulty of the job asha catchment areas are based on approximate population estimates with a target of about 1000 people per asha but nonetheless may vary from one asha to another this variation in catchment size could inadvertently lead to some households being more difficult to reach than others another jobrelated factor for the asha is monthly or seasonal variation in the number of pregnant women within a catchment in our data for 400 ashas the number of pregnant women in a catchment area at the time of the survey varied from 0 to 41 and likely varies sporadically during the year which could cause sudden jumps and reductions in workload that are beyond the ashas control another factor that affects asha reach is a common practice whereby mothers move back to their natal households to give birth so they can be near their parents and immediate families this indirectly affects ashas because expectant mothers are more likely to be acquainted with the ashas near their husbands family home asha programs also routinely add duties to what ashas are asked to do in their communities examples of this include conducting household surveys for some other government health initiative or assisting with drug administrations or campsworkshops on special topics the number of additional tasks that ashas are asked to assist with likely increases during the covid19 pandemic 29 some studies like the one by kumar et al 28 referenced above aggregate related behaviors into units to capture a more complete picture of a health service for example their full anc consists of taking 100 or more ifa tablets getting at least one tt injection and having four or more anc checkups a metric like this is highly useful for assessing service access in that to improve health across a region requires that individuals gain access to several services however a measure like this could be misleading if used uniquely for evaluating asha efficacy because it would combine factors at the program level with those at the individual level ifa tablets may be in short supply which is out of the ashas ability to control the mother may decide to register late for anc care which the asha may or may not be able to influence and may require some skills in persuasion rather than just service extension but just the same is not fully under her control and is different from a supply issue tt injections may involve negative misconceptions associated with vaccines or quality concerns for drugs distributed free of cost both of which are tied to perceptions and misinformation that the asha may try to persuasively combat but also go well beyond what she can directly control keeping in mind she has low pay and limited training anc checkups are visits out of the house and some mothers and their families may avoid these visits due to fear of evil eye while some mothers may not have available family members to accompany them to the facility 15 these are some of the various factors that can differentially impact the constituent parts of a composite score like full anc and further indicate the need to distinguish programmatic factors from individual ones many researchers are seeing a need to shift the ashas role more toward a facilitator which also requires various forms of improved programmatic support 79113031 home visits are valuable but ashas may have other routes for messaging many women are receiving asha visits outside the home or are having information sent to them by ashas via family members these other messaging routes may be effective and help buffer the effects of seemingly less than ideal frequencies of home visits indeed finding multiple ways to meet with mothers is encouraged in the asha guidelines and one would expect that finding multiple messaging strategies via ones intuitive understanding of the community might be a skill that embedded chws develop over time raising this possibility is not intended to suggest that home visits are not valuable or critical but rather to suggest that ashas may have ways to get their messages into the cultural system without a formal visit which could be useful if there are occasionally barriers to making home visits additionally evaluations of asha performance that target home visits should also consider other kinds of contacts even if they occur outside of the home especially since these are encouraged in asha guidelines the measurements of asha efficacy sometimes conflict with the intention of the asha program as mentioned above several previous evaluations of ashas or the asha program have found mixed and negative results across the papers summarized in a recent thorough review by scott et al 14 are a variety of interesting and important studies that vary greatly from one another this variation makes it difficult to form general impressions about the overall effect of the asha program on the question of mixed results however we would like to note a few points from our study one is that the effect of the asha on behavioral uptake is positive given that efficacy is evaluated as raising the probability that mothers practice recommended health behaviors perhaps in some classification schemes the results reported here could be characterized as mixed because we show that ashas could be underperforming if performance is measured by meeting a recommended target number of anc home visits or by ensuring that asha services reach 100 of the mothers in an ashas catchment area that is we find asha contacts have a strong positive influence but that the contacts may not be sufficiently widespread if so there could be ways to amplify these positive effects by finding ways to increase the frequency or reach of these visits or in finding other ways for ashas to get messages to mothers this begs the question of how many more anc visits would it take to reach some kind of ceilingeffect or diminishing return with respect to the increased uptake of recommended behaviors by mothers it also begs the question of what is responsible for the association between ashas and the uptake of recommended behaviors direct visits during pregnancy are clearly a valuable messaging opportunity the earlier the first home visit occurs the more likely it is that women complete their ifa treatments for example which is partly why we consider not concealing the pregnancy from ashas as a biomedicallyrecommended behavior it may also be the case that as the asha becomes more present and her messaging permeates the cultural milieu of a village many women may associate the asha with the biomedicallyrecommended behaviors even if they have not had many oneonone visits from an asha lastly if an ashas efficacy is going to be considered mixed or negative based on a number of visits of a given type there needs to be clear evidence that more visits of that type would be optimal or that better alternatives to the type do not exist which is a matter for further research if a greater emphasis is placed on increasing asha home visits during pregnancy in the absence of further programmatic support what allowances are there that some other service will decline in frequency as a result like many chw programs the asha program is built on the notion that there is something costeffective and outcomepromoting from attempting to recruit local workers who share customs and beliefs with their communities evaluations of either individuallevel asha performance or of the asha program should keep this foundational rationale in mind we suggest that evaluations should be more calibrated to what ashas actually do given resources training and programmatic constraints evaluations should be designed with a rationale that complements that of the asha program for further study there is a broad association between ashas and generally healthpositive advice for that advice to reach critical thresholds it has to spread through various channels and it may be that an undertapped aspect of chws is relying on their abilities to recognize and effectively utilize those channels as they grow into their roles training programs could be updated to facilitate that ideally in collaboration with experienced ashas likewise figs 5 and6 show that the asha is one among many sources of influence many of which are based in the community or even the household finding ways to leverage alliances among these sources of influence may be a key to shifting the asha from service extender to cultural facilitator 3233 conclusion many previous evaluations of asha efficacy have either not included actual measures of perinatal health behaviors or have looked at a fairly narrow range of them here we consider 12 perinatal health behaviors and 9 potential sources of influence ashas have a positive influence on all 12 of these behaviors in every case they are among the influencers with the strongest positive effect are sometimes the ones with the largest effect and always have a statistically positive effect we conclude that interactions between ashas and mothers positively impact mothers to engage in healthpromoting behaviors our data are consistent with recommendations to increase asha contact with mothers as well as improve asha training to more effectively educate mothers about healthpromoting behaviors we also encourage more studies that attempt to move beyond simple linear connections between an incentive or a particular kind of visit and a single outcome finally we recommend further attention be paid to understanding how the efficacy of ashas can be further strengthened by matching mechanisms and sources of influence with particular focal behaviors 11 ashas are effective catalysts of behavior change but increasing their efficacy further will require changes at the program level all data used in this submission are publicly available without restriction via a dedicated github page that can be found at this link ashaefficacydataarchive supporting information s1 s3 table results of selected logistic regression model that includes controls influencers behaviors and influencer x behavior interactions s4 table results of moderation analysis that includes controls and an interaction between each moderator and asha interaction score s5 table results of moderation analysis that includes controls and an interaction between each moderator and asha interaction score funding acquisition

community health worker chw programs are essential for expanding health services to many areas of the world and improving uptake of recommended behaviors one of these programs called accredited social health activists asha was initiated by the government of india in 2005 and now has a workforce of about 1 million ashas primarily focus on improving maternal and child health but also support other health initiatives evaluations of asha efficacy have found a range of results from negative to mixed to positive clarity in forming a general impression of asha efficacy is hindered by the use of a wide range of evaluation criteria across studies a lack of comparison to other sources of behavioral influence and a focus on a small number of behaviors per study we analyze survey data for 1166 mothers from bihar india to assess the influence of ashas and eight other health influencers on the uptake of 12 perinatal health behaviors we find that ashas are highly effective at increasing the probability that women selfreport having practiced biomedicallyrecommended behaviors the ashas overall positive effect is larger than any of the nine health influencer categories in our study covering public private and community sources but their reach needs to be more widely extended to mothers who lack sufficient contact with ashas we conclude that interactions between ashas and mothers positively impact the uptake of recommended perinatal health behaviors asha training and program evaluation need to distinguish between individuallevel and programlevel factors in seeking ways to remove barriers that affect the reach of asha services

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introduction fecal microbiota transplantation is a procedure involving the transfer of stool from a healthy screened donor into the intestinal tract of a diseased recipient fmt is claimed to possess a therapeutic effect by remodeling the gut microbiota and treating microbial dysbiosis which is often defined as an imbalance in the gut open access correspondence 1 school of pharmacy department of pharmaceutics and pharmaceutical technology the university of jordan amman 11942 jordan full list of author information is available at the end of the article microbial community that is associated with disease 1 2 3 4 traditionally fmt is prepared as a crude fecal matter using a manual method where the fecal matter or stool is collected from a tested donor mixed with a saline or other solution strained and placed in a patient by colonoscopy endoscopy sigmoidoscopy or enema 5 recently a standardized automated washed microbiota transplant preparation method was introduced and was found to significantly reduce fmtrelated adverse events fmt has been used to successfully treat recurrent clostridium difficile infection 67 and guidelines towards its safe use are continuously evolving as such the infectious diseases society of america 8 society for healthcare epidemiology of america 9 and the world society of emergency surgery 10 have recently updated the clinical practice guidelines for clostridium difficile infection the updated isda and shea guidelines include the use of fmt as a cdi treatment in the second or subsequent recurrence with strong to moderate strength of recommendation and quality of evidence 89 according to the food and drug administration regulation of the use of fmt for recurrent cdi should clearly be explained as being an experimental approach as such the use of fmt is a mix of a clinical trial and standard care 11 the long history of fmt has witnessed an evolution in the methodology clinical strategies and delivery methods 12 therefore modernized fmt guidelines have been formulated 61314 nevertheless efforts are still needed for establishing standardized protocols for stool preparation fmt administration and delivery methods donors and recipients selection criteria 15 and stool banking 1617 meanwhile there has been great interest in fmt applications and growing evidence suggests its potential use in the management of gi conditions other than recurrent cdi 18 including ulcerative colitis 19 cardiometabolic syndrome 20 crohns disease 21 irritable bowel syndrome 22 and some neurological disorders such as multiple sclerosis 23 and parkinsons disease 24 nevertheless these potential therapeutic uses face many challenges 25 and thus more safety and efficacy studies are still needed moreover technical legislative regulatory ethical and social concerns in creating a standardized treatment modality should be addressed and resolved fmt therapy had faced and is still facing numerous regulatory ethical cultural and social challenges ethical challenges include 26 informed consent and the vulnerability of patients determining what is a suitable healthy donor safety and risk commercialization and potential exploitation of vulnerable patients and public health implications 26 personal identity and family relations 27 28 29 have been identified as additional ethical challenges the findings that altered microbiota can be passed to the offspring 30 and the possibility of family members to be potential secondary recipients raised calls for the consideration of the ethical complexity and challenges associated with microbiome research in fmt procedures and regulations 31 moreover due to the cultural and religious constraints of certain types of diet and the effect of dietary intake on individuals microbiome composition dietary intake might be considered an ethical challenge in fmt consenting procedure 28 29 30 31 all these challenges make it very difficult to demarcate the regulatory framework indeed the regulatory status of fmt has been changed several times and is continuously modified 3233 despite the reported therapeutic effects of fmt in recurrent cdi management its use is limited by many factors including lack of specialized centers difficulties with donor selection and recruitment and difficulties related to regulation and safety monitoring 1734 in addition to the social and ethical challenges described above in contrast to the long standing fmt use in china fmt is not regulated as a therapeutic tool in jordan nor is officially practiced in light of the growing evidence of fmt therapeutic effectiveness in the management of different git dysbiosis related disorders we expect it will become an approach used by jordanian practitioners in the future nevertheless the differences in the cultural social and religious make up of jordanian and islamic conservative tradition compared to china or western countries might entail unique ethical challenges towards fmt therapy and thus specific regulations for its use indeed it has been shown that the crosscultural differences between chinese 26 and western cultures impacted the shaping of their fmt regulations 3536 the aim of our current study was to investigate the knowledge attitudes and perceptions of ethical and social issues regarding fmt uses by jordanian healthcare providers to highlight the ethical challenges in the context of jordans cultural and social makeup methods study design settings and subjects this was an observational crosssectional study design the aim of which was to assess knowledge attitudes and perceptions of ethical and social issues of fmt among jordanian healthcare professionals the study was conducted in amman jordan between june and august 2019 using convenient sampling 300 various healthcare practitioners including gastroenterologist andor internists medical doctors nurses medical laboratory technicians and pharmacists were invited to participate in the study and asked to fill a paperbased questionnaire the goals of the study as well as the questionnaire were thoroughly explained to each participant before getting their verbal consent to participate their participation was voluntary and their responses were anonymous this study was approved by the institutional review board of the jordan university hospital dated 3112019 questionnaire development the questionnaire was based on that used by a previous study by ma et al 26 with some modifications the latter is distributed under the terms of the creative commons attribution 40 international license in brief the questionnaire consisted of four sections comprising 20 items general knowledge and attitudes towards fmt perception of ethical concerns belief about social and regulatory issues and views about fmt bank ethics question formats included single choice multiplechoice and written short answer to this questionnaire we added questions about cultural constraints including religion dietary intake and alcohol consumption for a subset of participants moreover using an openended question participants were asked to write any other comments regarding fmt that they wish to make sample size calculation for the questionnaire sample size was calculated based on orourke et al 37 where it is recommended that the number of subjects should be 510 timesthe number of items or 100 given that we have 21 items in our questionnaire a sample size of 105210 participants was considered representative for the purpose of this study statistical analysis data were analyzed using statistical package for social science version 22 the descriptive analysis was done using frequencies and percentages chisquare test was used to compare practitioners who were familiar and or involved with fmt vs those who were not an arbitrary negative score was created from the negative views about fmt assigning a value of 1 for answers with a negative attitude and 0 for positive attitudes independent students ttest was used to compare the score between practitioners familiar with fmt vs those who are not in addition anova test was done to check the difference by profession pvalue less than 005 was considered statistically significant results data were collected from 300 healthcare professionals table 1 below describes results as frequency and percentage most of the participants were gastroenterologist followed by medical doctors the vast majority did not perform fmt but have heard about it ethics regarding ethical issues it seems most of the responders were skeptical and not supportive of using the fmt method a large percent thought that the safety and efficacy of this technique are limited and another 293 reported that there is no evidence to support its use when asked if the methods were medically indicated and ethically approved would they use it still only 5 would refer a patient for fmt about 40 would not perform it due to concerns about medical litigation followed by fear of infections and lack of knowledge of longterm safety and efficacy but 483 would do it when other treatments fail and another 297 would do it if there was a need for organic or natural treatments the majority will protect the patients confidentiality via doubleblinding not everyone was willing to inform the patients about all risks as some would inform them about actual physical risk from the procedure and others will inform patients depending on their comprehension concerning the fmt bank all participants viewed that there is a problem in donors anonymity and data deidentification and 477 were worried about the consent methods the ethical concerns were numerous and included the mode of informed consent privacy protection and ownership of samples perceptions about the use and efficacy of fmt only 207 believed that fmt was overrated and 42 did not agree that fmt value is overrated and the rest did not know interestingly all practitioners would perform this procedure through the lower gastrointestinal rather than the upper gastrointestinal tract a total of 43 supported the statement that fmt negatively impacts the patients dignity as for social and regulatory issues 87 believed that the application of fmt should be suspended and it is not urgent to apply 84 believe that fmt will not have other future applications and 100 said that it should not be used as the first line for cdi barriers to the use of fmt were due to lack of guidelines and unknown mechanisms of action of this treatment doityourself fmtmeaning lay individuals adopting fmt clinical techniques performed on andor by themselves at home social media has facilitated widespread exposure to and awareness of the relationship between the gut microbiome and human health 38 given the availability of the necessary raw materials the straightforward technique of fmt administration and anecdotal success stories online numerous websites have already sprung up advertising home diyfmt kits as a directtoconsumer product the concept of commercialization of fmt raises concerns regarding proprietary rights accessibility of data and biological material and the implications of dtc products 39 with regards to commercialization 813 of participants thought that diy and dtc advertisement is common in other areas internationally diy practices have been developed to include different therapeutic areas such as diyfmt 38 diydiet 40 diyautomated insulin delivery 41 in jordan people are becoming increasingly familiar with drugs and their brand names and are practicing selfmedication 42 including the use of antimicrobials 43 which can be considered as a concerning diy health practice area cultural aspects for a subset of participants we asked about the cultural constraints that might affect the choice of performing fmt for 52 it was the religion then dietary intake and alcohol consumption due to the scarce number of practitioners who fall in the category of being familiar andor involved in fmt the comparison of different variables according to this parameter would not be accurate due to the large difference in sample size between almost all the healthcare providers have heard of fmt but only 43 performed or were involved with this procedure an independent ttest showed that there was no significant difference in the negative views score between practitioners familiar with fmt compared to those who are not although medical doctors had higher negative scores than other healthcare practitioners there were no statistically significant differences between scores them the mean negative views score regarding fmt among different healthcare practitioners are shown in table 2 in addition an openended question allowed participants to express their views about fmt in a category called others seventy of them answered this question 17 of them expressed religious objections and 30 of the participants declared the need to consider the religious point of view and to seek fatwa moreover 41 of them were concerned about lack of experience and clinical trials in the arab region and 11 thought it should be sought as last resort with strict monitoring or might have role in future discussion fmt harmonized regulations are lacking and the current regulatory status ranges from nonexisting to strictly regulated 32 for now the us fda had classified fmt as a live biotherapeutic drug that requires the submission of an investigational new drug application for its therapeutic uses 33 cdi has been recently exempted from ind application filing which was a decision that was received with high appreciation by clinicians to use fmt in a fatal ailment meanwhile strict regulation and control over the use of such treatment were recommended by renzong qiu 2017 44 although fmt has received great attention lately there is still a gap in the understanding of fmt around the world even in countries where it is being used 4546 a wider acceptance of this therapy can be achieved by the implementation of regulations addressing the ethical and social issues facing its application such as the autonomy and the privacy of patients and donors promoting research investigating its safety and efficacy and the use of standardized methods in its preparation and application including stool banking 121617 moreover to promote its dissemination to countries in the middle east such as jordan country specific social norms tradition customs and religious backgrounds and structures should be taken into consideration towards introducing and regulating fmt 44 our results demonstrated that the majority of the respondents heard of fmt treatment but did not practice it in contrast to jordan where fmt is not regulated nor practiced yet fmt has been practiced in china since the fourth century where traditional chinese medicine used yellow soup fecal slurry orally to treat food poisoning and diarrhea 2647 this justifies the high familiarity of this treatment modality among chinese clinicians 26 nevertheless the familiarity does not guarantee experience in using it by clinicians zipursky et al 48 in their study reported that physicians have limited experience with fmt despite having treated patients with multiple recurrent cdis in general our study population was not enthusiastic about nor supportive of the introduction of such treatment they did not see its promising utility for other future applications barriers towards the promotion and recommendation of fmt include mostly the absence of official guidelines and regulations followed by the risk of infections and longterm risk and safety this is in concordance with kelly et al 49 who reported on physicians attitudes towards fmt in 2010 at the american college of gastroenterologist meeting they found that 40 of physicians who had heard of fmt were not willing to try it pending further demonstration of its efficacy safety nevertheless kelly et al showed that physicians recommendation was positively influenced by patients perceived acceptance 4950 this was not what our respondents think in general unwillingness for recommending fmt treatment were related to many factors the limited knowledge among the study population 51 the limited practicing numbers 36 and the yuckfactor 52 other reasons for physicians not offering or referring a patient for fmt were not having the right clinical situation the belief that patients would find it too unappealing and institutional or logistical barriers 48 in his commentary brandt et al 52 related physicians hesitation to recommend fmt to the limited randomized controlled trials to show effectiveness and safety he predicted that patients needs in addition to the availability of aesthetically acceptable formulations are influential parameters towards the acceptance of this treatment modality among physicians indeed we found that the lower part of gi was the only acceptable route of administration of fmt this might affect how the accepted fmt formulation will need to be regulated in jordan in the future in support of the international legislations our respondents will not recommend fmt as a firstline treatment but only recommend it when there is a failure of conventional treatment or they want organic natural treatments this is in agreement with the iranian clinicians and gastroenterologists attitudes who reported a willingness of accepting fmt as a therapeutic option if it is scientifically justified and ethically approved given it was used as synthetic microbiota rather than fm 53 clinical efficacy is a crucial factor that maintainspatients positive attitudes towards fecal microbiota transplantation 54 and physicians advising and referring patients to fmt treatment modality the reported physicians responses regarding the efficacy and safety of fmt were diverse while a major concern about fmt efficacy and safety was reported among chinese clinicians 39 zipursky et al 48 have reported minor doubts about fmts efficacy and safety among physician respondents at dartmouthhitchcock medical center and baylor college of medicine in light of the abovedescribed barriers and limited efforts in increasing the awareness of the uses and efficacy and safety of fmt treatment modality we predict that the introduction and the regulation of this treatment modality in jordan is not going to be soon accordingly efforts should be put forth for increasing awareness about its utility and effectiveness and to highlight the ethical and culturalreligious challenges towards its application such as patients vulnerability donors anonymity and data deidentification and the consenting procedure moreover legislative and ethical challenges facing the establishment of biobanks in jordan including privacy and confidentiality specimen ownership and informed consent should be addressed 55 according to the us fda during the investigational use of fmt the potential risks and benefits including the unknown risks and the longterm risks should be clarified for qualified patients during the consenting procedure consenting is an ethical challenge in fmt which was recognized by close to 50 of our participants the fmt consenting procedure should consider patients vulnerability unforeseen long term risks and limited knowledge of the actual benefits and risks to the treatment in addition to the universal ethical requirement of biomedical research 56 ma et al 26 believe patients compromised decisionmaking capacity and vulnerability are the main challenges to informed consent they consider cdi patients vulnerable and desperate individuals who can be easily affected by emotive language as being natural and safe whether from physicians or the media this was opposed by bunnik et al 11 who believe that it is not the vulnerability or capacity to consent but rather the inadequate information that poses difficulties with regards to the fmt consenting procedure other important challenging parameters in the consenting process are culturalreligious or personal ideological food restrictions of stranger donor in their commentary 57 authors questioned whether informed consent to fmt can be obtained without information about the donors diet this an important ethical challenge that is very relevant to our regions population that is mostly muslim thus observing the religious commitment to halal nonalcoholic containing foods and beverages is essential our respondents think that religion dietary and alcoholic consumption will be considered as a barrier in patients acceptance of fmt accordingly we perceive that it could be necessary to declare the donors dietary habits to obtain an autonomous decision in this region an important parameter that was highlighted by the respondents comments was the need to consider the religious point of view and to seek fatwa this was declared by 30 of the participants in addition to their perception of the need for more knowledge about safety therefore we concluded that our healthcare practitioners are reluctant to use fmt because of concerns about safety and religious beliefs ma et al 58 highlighted important cultural and religious beliefs that might affect the public acceptance of fmt some people might consider fmt an unsanitary treatment and some will limit the donor to those who eat specific food such as vegans or those with a specific religion such as muslim patients who might not accept fecal transplant from nonmuslim donors all these barriers entail the importance of demarcating regionspecific fmt regulations that take into consideration the cultural and religious background of the public although there is a growing awareness of ethics in human research nevertheless alahmad et al have shown that research ethics regulations and guidelines in middle eastern arab countries suffer from various degrees of deficiencies with regards to ethical protection 59 they recommended that social norms traditions customs and familial ties should all be taken into consideration when developing policies and regulations in interviews with medical professionals from the middle east alahmad et al 60 reported the social importance of protecting confidentiality deidentification and anonymity of donors scored 100 as being an ethical concern in conducting fmt among the jordanian clinicians they mostly agreed that confidentiality can be protected by double blinding both the donor and the receiver and to ensure the confidentiality of patient information during communication with others limitations firstly our study adopted convenient sampling from the capital of jordan therefore the findings may not be generalizable to other provinces or worldwide however the objective of this study was to assess the perceptions of healthcare providers regarding ethical and social concerns about fmt as the first such study among this population and we do not expect our results will substantially change among other jordanian physicians secondly we had a limited number of physicians who used fmt making it more difficult to fully comprehend the procedure and its risks and benefits and the attitudes might change if they had a positive experience in treating patients with it in conclusion our study demonstrated a lack of enthusiasm to implement fmt in jordan by healthcare providers although there is general support for its potential use as a second line of treatment when other traditional medical treatment fails there are complex ethical religious and practicebased challenges that need to be addressed before fmt becomes an established practice future studies should examine fmt from local traditional and especially religious perspectives as well as other barriers found in our study as well as consenting privacy and risks patient perspectives are lacking and would be important to understand the level of acceptability among those who need fmt furthermore there should be providing more education to increase the understanding of fmt benefits and risks among jordanian healthcare practitioners availability of data and material the data are available upon request from the corresponding author agbakri juedujo abbreviations fmt fecal microbiota transplant idsa infectious diseases society of america shea society for healthcare epidemiology of america wses world society of emergency surgery cdi clostridium difficile infection irb institutional review board diy doityourself dtc directtoconsumer sd standard deviation us fda the united states food and drug administration competing interests the authors declare that they have no competing interests • fast convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data including large and complex data types • gold open access which fosters wider collaboration and increased citations maximum visibility for your research over 100m website views per year • at bmc research is always in progress learn more biomedcentralcomsubmissions ready to submit your research ready to submit your research choose bmc and benefit from choose bmc and benefit from publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

background fecal microbiota transplant fmt is a treatment modality that involves the introduction of stool from a healthy prescreened donor into the gastrointestinal tract of a patient it exerts its therapeutic effects by remodeling the gut microbiota and treating microbial dysbiosisimbalance fmt is not regulated in jordan and regulatory effort for fmt therapy in jordan an islamic conservative country might be faced with unique cultural social religious and ethical challenges we aimed to assess knowledge attitudes and perceptions of ethical and social issues of fmt use among jordanian healthcare professionals methods an observational crosssectional study design was used to assess knowledge attitudes and perceptions of ethical and social issues of fmt among 300 jordanian healthcare professionals results a large proportion 39 thought that the safety and efficacy of this technique are limited and 293 thought there is no evidence to support its use almost all 95 responded that they would only perform it in certain cases if ethically justified and 483 would use it due to treatment failure of other approaches when reporting about reasons for not using it 40 reported that they would not perform it due to concerns about medical litigation fear of infections 38 and lack of knowledge of long safety and efficacy 313 interestingly all practitioners said they would perform this procedure through the lower rather than upper gastrointestinal tract modality and the majority will protect the patients confidentiality via doubleblinding 433 for a subset of participants n 100 the cultural constraints that might affect the choice of performing fmt were mainly due to donors religion followed by dietary intake and alcohol consumptionour healthcare practitioners are generally reluctant to use the fmt modality due to religious and ethical reasons but would consider it if there was a failure of other treatment and after taking into consideration many legislative social ethical and practicebased challenges including safety efficacy and absence of guidelines

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i introduction currently kenya is faced with serious socioeconomic problems related to the high prevalence of alcohol and drug abuse the wider ramifications include illhealth disability declined productivity unemployment financial instability and disintegration of families which in turn has inflicted untold suffering on parents and families as productive members become wired into drugs today substance abuse in kenya has become rampant in urban areas owing to the liberal use of drugs and substances especially among young people which in turn has resulted in increased crimes and domestic violence in numerous households across the country the wider effects of drugs and substance abuse especially among the youths in the country have prompted the government to intervene to remedy the situation the intervention has been mixed ranging from policies to preventive programs according to stringer and baker africa as a continent represents a unique but complex case in the context of drugs and substance abuse the continent remains one of the major supplies of some drugs such as cannabis despite the eradication efforts put in place the continent continues to grapple with the problem of escalation of substance abuse and trafficking the continents role in the drugs global supply chain continues to increase at an alarming rate currently it is the second largest producer trafficker and consumer of cannabis representing 26 per cent of global seizures of cannabis intense threats of drug trafficking have been linked to factors such as abject poverty psychological disorders fragile health care systems policies on drugs that are largely focused on repression and inadequate specialized treatment and rehabilitation facilities to mention a few muoti adds that the response by the continent has been mixed and could be narrowed to individual countries which continue to bear the brunt of drugs and substance abuse most african countries have stepped up the treatment and rehabilitation programs in a bid to mitigate the crisis however most healthcare systems are incapacitated to meet the needs of their citizens owing to their underfunding among other things more precisely the treatment and rehabilitation programs of most african countries are largely dependent on assistance from relevant international organizations such as world health organisation united nations office on drug and licensed under creative commons attribution crime and nongovernmental organisations with its huge population being young people the continent remains vulnerable to drug and substance abuse and is becoming a destined market for the thriving illicit drug industry in response the continent through the african union has established an action plan for drug control andcrime prevention the plan mandate is to revamp the health security and socioeconomic wellbeing of african citizens by addressing the trafficking of drugs and the persistence of drug use in all its forms and manifestations and ultimately prevent the onset of drug consumption additionally the plan is embedded in education prevention treatment and recovery as well as the provision of rehabilitation services as a collective plan it is incumbent upon the african countries to implement and domesticate it however much has not been achieved and the menace of drugs and substances continues to be an endemic problem on the continent a gloomy picture on the prevalence of drugs and substance abuse was painted by a survey conducted by nacada in 2016 with an aim of assessing the status of drugs and substance abuse in the country from the study it was found that 122 of the respondents in the age bracket of 1565 years were consuming alcohol 83 tobacco 41 and 10 were consuming khat and bhang respectively similarly the study found that 60 of the total respondents were abusing multiple drugs and substances furthermore alcohol related disorders were the leading with 104 followed by tobacco disorders at 68 with khatrelated disorders standing at 31 per cent similarly another study by ronoh which was conducted in selected public and private universities in the country revealed a high prevalent rate of drugs and substance abuse in higher institutions of learning he noted that families institutions of learning and places of work have undergone agonizing impacts if the menace particularly in the universities he found that the problem was rampant and was being aggravated by numerous factors including personal freedom excessive amount of free time a wide range of demands on the students the psychological impact of interactions and making of new friends who may lure them into drugs and substance abuse to mitigate the situation the study found that the universities across the country have come up with preventive programs and social support services to implement the intervention measures these are just but a few the numerous studies that reveal the real situation of drugs and substance abuse especially among the youths drug and substance abuse is increasingly being recognized as an emerging health issue in the region alongside factors like pervasive poverty increased unemployment rates as well as the spread of hivaids the coastal region especially mombasa and kilifi has attracted unparalleled media coverage with significant cases and documentaries on drug trafficking and its usage this attests to the fact that drugs and substance use is a deeply rooted problem and humaninduced disaster that requires urgent attention from all the relevant stakeholders dozens of people have been reported to have perished as a result of this menace in response the government has initiated a series of mitigation and prevention programs which have been manifested in learning institutions working places communities public education and advocacy as well as providing accessibility to effective and holistic treatment and rehabilitation programs to mention a few objective the objective of this study was to examine the nature of drugs and substance abuse in selected counties in the coastal region the chapter discusses different parameters on the nature of drugs and substance abuse including causes of drugs abuse types of drugs abused prevalence of drug and substance abuse and effects of drugs and substance abuse ii methodology the study used descriptive and evaluative research designs with data collected through interviews focus group discussions observations and questionnaires the scope of the study was limited to the two counties in the coastal region of kenya data was collected from 552 respondents who included 384 household heads 20 victims 2 county education officers 2 county commissioners 2 county health officers 70 administrative chiefs 102 village elders 9 head of nacada officers and 8 religious leaders the study used descriptive and evaluative research designs with data collected through interviews focus group discussions observations and questionnaires quantitative data was analyzed through spss version 26 and was presented using tables figures and charts qualitative data was analyzed using thematic narrations and presented using descriptions and verbatim quotations licensed under creative commons attribution iii results and discussions nature of drug abuse in the coastal region in this section the study examined the nature of drug abuse in the coastal region exploring causes of drug abuse the types of drugs abused the methods of acquisition of the drugs the prevalence of drug abuse the methods of drug consumption and finally the effects of the peril at the individual family and community levels the results and findings of the first objective of the study are discussed in details the findings of this section of the study are based on the results from questionnaires fdgs and interview responses a total of 552 respondents were surveyed in this study the response rate from the respondents was achieved at 100 due to the involvement of research assistants in this study who aided with data collection interviews scheduling and the interview processes demographics of victims understanding the demographics of victims of drugs and substance abuse is an essential aspect of comprehending the prevalence and nature of drug and substance abuse in any region in the coastal region of kenya where drug abuse has been a growing concern investigating the demographics of drug users can provide valuable insights into the characteristics of those who are most vulnerable to drug abuse and the factors that may be contributing to the problem in this case therefore in the bid to understand the nature of drugs and substance abuse it was necessary to understand the sociodemographic features of victims this was crucial in understanding the most vulnerable group and factors that increase their vulnerability in return this helps in building resilience under the demographics of users this study investigated the following features of the drug abusing population age gender and socioeconomic status the respondents were required to mark which population category they felt were the most abusers of drugs the results are presented table 1 age group according to the findings of the study on the nature of drug abuse in the coastal region age was a significant factor among drug abusers the study revealed that the highest percentage of drug abusers fell within the age group of 2635 years which accounted for 3516 of the total respondents the age group of 1825 years was the secondhighest group with a prevalence rate of 2552 followed by the age group of 3645 years with 2474 the age group of 46 years and above had the lowest prevalence rate of drug abuse with 1458 licensed under creative commons attribution the results of the study indicate that a majority of the drug and substance abuse victims are below 40 years they start at a young age and this is what makes everything complex these days even young children aged 912 years are taking drugs they collect muguka leaves from the base when they are 34 years since the society has normalized this negative trend of drugs and substance abuse the children grow up knowing that it is just normal consequently they embrace the culture of taking drugs from young age the age group of 1529 years had the highest prevalence rate of drug abuse drug abuse was prevalent among young people due to factors such as peer pressure easy accessibility of drugs and lack of parental guidance as outlined by nacada this finding supports the results of the current study which also identified the age group of 1835 years as the most vulnerable to drug abuse the age group between 1529 years comprises of the high population of idlers in mombasa and kilifi these are the individuals who have no meaningful job and they tend to spend time together doing the same things since they are in same age group social learning theory points out that people who spend time together opt to learn from each other as they observe what their peers are doing in the same way people who spend time together will learn drug abuse tactics from each other through social learning skills such as observation and imitation another study conducted by who found that drug abuse is more prevalent among socioeconomically disadvantaged young populations the study notes that people living in povertystricken areas especially the young ones are more likely to engage in drug use due to various factors such as lack of access to education and employment opportunities drug abuse rates among different age groups vary by drug type often young people aged 1825 years are more likely to use illicit drugs such as marijuana and prescription drugs while older age groups are more likely to use alcohol and tobacco as explained by moh reports the report reflects the data from the current study which identified young people as the highest group of drug abusers in the coastal region in kilifi and mombasa counties drugs are readily available due to the geographical location of the area gender the results from questionnaires found that 7526 of drug abusers in the region are male while only 2474 are female this indicates a significant gender disparity in drug abuse in the coastal region this study confirms the results of other studies that have linked drug usage to gender sambai et al observed for instance that drug usage is more common among males than among women in kenya the research also showed that drug usage was more common among males and that it is intensively prevalent at a younger age mainga et al conducted another research on substance abuse in kenya and found that males were more likely to be heavy users than females unodc concluded that there is a worldwide gender gap in drug usage almost everywhere in the globe males were found to consume drugs at higher rates than women women drug users are more likely to experience prejudice and hostility than their male counterparts according to the research according to research by bitta et al in kenya 702 of drug abusers are male this is a much higher percentage than among women a majority of drug abusers in kenyan urban centers are males according to a study in 2021 similarly ahmad et al study in nigeria shows a similarly high proportion of male participants in drug and substance abuse socioeconomic status the findings of the study indicate that 349 of the drug abusing population in the region fall under the low socioeconomic status category while 4453 belongs to the middle socioeconomic status group the high socioeconomic status group comprises of 2057 of the drug abusing population in the region several studies have found an association between income level and drug abuse maraka et al observed a correlation between having a lower socioeconomic position and substance misuse stress social pressure and easy availability to drugs were also shown to moderate the association between socioeconomic level and drug consumption adolescents from middleand upperclass backgrounds were shown in another research by njomo et al to be more likely to engage in substance misuse researchers also discovered that parental involvement and peer pressure moderated the association between socioeconomic position and substance addiction poverty unemployment and a lack of education were also identified as major contributors to drug consumption in a survey conducted by the unodc the study highlighted the need of addressing socioeconomic issues in drug misuse prevention and treatment further the study indicates that those living in poverty were more likely to have used illegal substances compared to those living above the poverty line with a correlation between drug addiction and not having a job or health insurance licensed under creative commons attribution education the findings indicate that people with little or no education are vulnerable to drugs abuse among the respondents those with no education had the highest percentage of drug abuse at 198 those who had only completed primary education follow closely with 344 those who had completed secondary education are at 302 while those with tertiary education have the lowest percentage of drug abuse at 156 several studies including a report by unodc have examined the relationship between schooling and drug abuse people with less education were found to have a higher risk of drug use compared to those with a higher level of education this is in line with the results of the research which showed that many drug users in the coastal areas had low levels of education the kenyan ministry of health published results of a research on drug misuse and literacy in 2018 those with less education and lower incomes were shown to have a greater prevalence of drug misuse the studys results urged the launch of publicawareness campaigns to combat the root causes of drug abuse nkonge discovered that high school graduates have a much reduced risk of drug usage than high school dropouts the likelihood of drug usage among young people was also observed to decrease with increasing levels of education these results provide credence to the argument that formal education may significantly curb drug usage drug route administration to understand how drugs are taken the household heads were asked to explain methods of drugs and substances abuse through an open ended questionnaire the results of the questionnaires are triangulated with what other respondents indicated during interviews and fgds and are discussed in this section oral administration the oral route of drug administration is one most accepted by many individuals both for the licit and illicit drugs because it is a less invasive and intimidating route there are numerous drugs that are abused orally which includes both prescription and club drugs the drugs that are administered through the oral route are khatmiraa and cannabis however cannabis that is taken through the oral route is not as effective as the heated one this outlines the aspect that cannabis can be administered through various routes but there is the preferred one due to the achievement of the desired effect the oral route of drug administration is inclusive of such processes as chewing and swallowing for such drugs as khat intravenous route injectable drugs are commonly used due to their high bioavailability that accounts for their ability to make the abuser get more immediate high many drug users inject the drugs directly into their systems the administration route is a dangerous one in that many of the injecting drug users usually end up sharing the body piercing tools including needles and syringes the factor has doubled the chance of such parties being infected with infectious diseases such as hepatitis and hivaids thus the method is invasive compared to the oral administration route due to the introduction of the drugs directly into the bloodstream high bioavailability is achieved the result has been an increased chance for the event of an overdose of the drug being abused which is a potentially risky aspect that can lead to the death of a victim snorting and sniffing snorting and sniffing of drugs are methods of drug administration intranasally sniffing is at times referred to as nasal insufflation sniffing has been applicable where the individuals with suds take such drugs as cocaine heroin and prescription pills like adderall or vicodin whose tablets can be crashed and snorted other than powder snorting has been found to involve the intake of drugs dissolved in liquid via a straw the have been a variety of names used to refer to the straw method with the major ones being inhaler bullet or bumper the process of sniffing or inhaling drugs has been found to take different forms including huffing or bagging huffing has become a common practice among teenagers who will not hesitate to use everyday household products such as glue cleaning products and aerosols like spray paint gases such as butane or propane have also been greatly abused as psychoactive substances through sniffing colloquially referred to as sniffing and in other cases bagging smoking results from interviews fgds and openended questionnaires the study established that smoking is generally an inhalation type of drug administration route smoking may occur occasionally or habitually as a result of drug licensed under creative commons attribution addiction there are several drugs whose intake usually occurs through smoking including bhang tobacco and cocaine smoking is an unhealthy habit in that it exposes the abuser to numerous health problems in some instances smoking has been proven to affect some of the psychiatric medications that could have been administered in the users body the medications affected include antidepressants anxiolytics antipsychotics and hypnotics their concentrations in the body are significantly reduced by smoke emanating from cigarettes in this case reduction in the effectiveness of the medications necessitates the increment of the doses required for the desired therapeutic effect rectal administration results from interviews fgds and openended questionnaires the study established that the rectal route of drug administration for drug abusers is not common however it is present and possible in normal circumstances suppositories are used rectally to provide local or systemic effects rectal route of drug administration among drug abusers has majorly been carried out by teenagers and young adults in the attempt to satisfy curiosity the method could appear as laughable of a matter as it seems however it carries various dangers whose effects on ones body can be serious and lasting drug abuse through the rectal route has been given popular names like buttchugging of boofing drugs where buttchugging involves alcohol causes of drugs and substance abuse from available literature the following have identified as causes of drug abuse using this information household heads were asked to indicate the main causes of drug and substance abuse in kilifi and mombasa counties the results are indicated in table 2 and discussed in the following sections idleness or a lack of meaningful activities or goals can be a contributing factor to drug abuse when individuals have too much free time on their hands and lack purpose they may turn to drugs as a way to fill the void and escape their boredom or unhappiness the issue of idleness as a cause of drug abuse was a major concern among the household heads in the coastal region with 99 of the respondents indicating it as a leading factor contributing to drug abuse this finding ranked idleness as the top cause of drug abuse in the study above socioeconomic factors and other associated factors spending too much free time means that the majority of kilifi and mombasa youths try to find a hobby or something to keep them busy it is during the free time that the youth observe how their fellow youths spend their time thus end up adopting the habit of abusing drugs this assertion is in line with social learning theory where individuals learn from others through observation as well as imitation it is what the youths observe during their free time that they tend to practice and eventually end up being drug addicts the findings of the study revealed that poverty was identified by 98 of the household heads as the second most important leading causes of drug abuse in the coastal region of kenya the high percentage of respondents that identified poverty as a cause of drug abuse highlights the impact of poverty unemployment and lack of access to education and healthcare on drug abuse in the region according to mwai et al indigence is a wellpronounced problem among many families in mombasa and kilifi the relationship between poverty and substance abuse is intertwined in that one may lead to the other the impoverished communities in these two counties are facing significantly higher rates of addiction to drug and substance abuse the severe longterm addiction among people experiencing poverty results from stress caused by financial instability unemployment lack of education emotional instability and mental illness society is socially interdependent in nature as it enhances its survival as suggested by functionalism theory in mombasa and kilifi resources are limited and the majority of residents are striving to survive this means that despite the interdependent nature of society sometimes it is difficult to meet the needs of each member this scenario is attributed to poverty and more often leads to stress to withstand the stressful situation that kilifi and mombasa residents have been subjected to by poverty they end up seeking refuge from drugs just to escape from the reality of life drug abuse as a result of poverty has a general impact which is to hinder functionality of the society according to the findings of the study mental health issues including substance induced psychosis depression anxiety disorders bipolar disorders substance induced mood disorders and cognitive impairment were cited by 97 of the respondent household heads in the study area as a cause of drug abuse ranking it as the third most common cause of drug abuse in the region during the focus group discussions a village elder pointed out that in the coastal community mental health is not given much attention there are many people who suffer from depression anxiety and trauma but do not seek help men and women suffer pressure from marriages children and young adults face a list of family problems including broken families deaths and failed marriages they turn to drugs as a way of coping with their emotional pain this is a major factor contributing to drug abuse in our community additionally drug abuse can also lead to mental health issues creating a vicious cycle individuals with a history of mental health issues were found to have a higher likelihood to engage in substance abuse in a study conducted by nacada confirming the findings of this study another research by kmhc found that kenyas inadequate number of psychiatrists is a major impediment to dealing with mental health problems and drug usage hence a high number of unattended individuals during an interview with a victim who was a university graduate he pointed out that i started using bhang when my wife left me because i could not provide i lost my marketing job during the covid 19 pandemic instead of supporting me she opted to go my sisters and my only brother criticized me claiming that i was careless i hated myself and felt like i am not man enough i started talking to myself i was too depressed i had no one who would listen to me i found myself associating with those who abuse drugs as they were not concerned about my past we shared good times smoking marijuana and this gave me satisfaction for some time i became an addict and up to now im still struggling to recover from drug dependency according to knbs the number of people suffering from mental health issues is on the rise in kenya with depression being the most frequent mental issue affecting different generations inclusively these individuals may resort to drug abuse or in some cases resort to professional help whereby they receive prescriptions of antidepressants that are later misused as outlined by moh in this report the ministry of health revealed that compared to those without mental health concerns those who misuse drugs are more likely to become addicted nearly a third of all people seeking substance abuse treatment in the kenya are diagnosed with a mental health disorder curiosity and experimentation were identified as a significant cause of drug abuse in the coastal region with a response rate of 96 and ranking 4 th on the causes of drug abuse in the coastal region it is evident that many individuals first attempt drug use out of curiosity or experimentation and this eventually leads to addiction during the focus group discussions a village elder stated that in my village many young people experiment with drugs out of curiosity without knowing the longterm effects of drug use some of them feel pressured by their peers to try drugs and this leads to addiction it is a serious issue that needs to be addressed since it affects the future of our youth these findings reflect previous studies that have linked curiosity and experimentation with drug abuse according to a report by united nations office on drugs and crime unodc young people try drugs out of curiosity or because they want to fit in with their peers the report further outlines that drug experimentation often leads to addiction and is a significant public health concern globally with curiosity being one of the primary motivations for drug use among young people during the interviews with a nacada official he pointed out that in my view the young people are curious they want to understand how it feels to produce a cloud of smoke from ones mouth they feel a strong urge to taste the green muguka leaves combined with njugu karanga licensed under creative commons attribution in the process of experimenting they end up becoming addicts the process of unlearning what they learn in this curiously is very complicated knbs also reported a worrying trend in drug abuse among young people in the coastal region where drug abuse was more prevalent among individuals aged between 15 and 34 years the report further stated that drug abuse was more common among males than females and it was more prevalent in urban areas than rural areas another report by moh evidenced that the majority of people who try drugs for the first time do so out of curiosity or to experiment the report indicated that people who start using drugs at a young age are more likely to become dependent on them later in life peer pressure amongst young adults was a significantly worrying trend according to the reports because young people often want to fit in with their peers and may engage in risky behaviors such as drug abuse to gain acceptance similarly a study by nacada found that drug experimentation was a significant contributor to drug abuse among young people in kenya the study found that young people were experimenting with new drugs such as crystal methamphetamine and cocaine and this was leading to addiction the study further noted that peer pressure and the desire to fit in were the primary reasons for drug experimentation among young people in this study 95 respondent household heads attributed drug abuse to poor parenting and neglectful parenting which ranked fifth among the major causes of drug abuse the high percentage suggests that family history is a significant concern in the coastal region and interventions targeting this factor could help prevent drug abuse during the focus group discussions a respondent village elder from kisauni stated that drug abuse is rampant in our area one of the reasons is family history where people inherit the habit of drug abuse from their parents and elders therefore this is a significant issue that needs to be addressed by the entire community further cases of family break ups increase the risk of drugs and other substance abuse through the mental weight of dissociation the village elders argued that decay of morals civilization and modernity has made it very complicated for people to remain in their families as a result women get married to different men after every few years they get children from each husband and when things do not work they leave with their children and get married again the children are brought up by the grand mothers who cannot fully control what they do the locals call them wajukuu wa bibi and they are very vulnerable to drugs and substance abuse most of these children end up in the dens using drugs as they have no one to take them to school or give them the right direction in life during an interview with the cec education from mombasa county she said that families in this area normalize what is forbidden in other communities a daughter will get married and then separate with the husband when she gets married to another man she will go with the kids from previous marriage the children from previous marriage locally referred to as wajukuu wa bibi will be taken to the grandparents of the new husband the old granny can hardly control these children and they end up abusing drugs so baldy this is a very dangerous trend in this region according to ashiono poor parenting has adversely influenced the rise of drug abuse in mombasa and kilifi where parents have failed in their parental responsibility they have left their children to be parented by teachers the menace of drug abuse caused by poor parenting has consumed much productive youth from mombasa and kilifi poor parenting variables that have led to drug abuse among many include neglectful upbringing authoritarian parents abuse of alcohol and other substances in the presence of children lack of parental support in daily activities and poorly monitoring or nonmonitoring parents mugalo further brings out that parental level of education has influenced drug and substance abuse neglectful parenting in mombasa and kilifi has promoted drug and substance abuse in adolescents and thus addiction into their youth there are many cases in which parents have neglected their childrens basic needs in these counties the trauma resulting from lack and want has forced the teens to seek coping mechanisms most of whom have turned to drugs the situation has been aggravated when parents are both harsh and neglectful of their childrens needs the harsh parents exhibit acts like yelling verbal or physical threats and hitting the emotional distress resulting from this treatment has led to drug abuse peer pressure was identified as one of the key factors contributing to drug abuse in the coastal region as highlighted by the responses of the 361 of 384 household heads surveyed in this study the prevalence of peer pressure as a cause of drug abuse was ranked sixth out of the nine factors explored with 94 of respondents indicating that it played a role in drug abuse among the youth in the region peer pressure for drugs and substances has been another dominant risk factor for children and adults in mombasa and kilifi the element of peer pressure has affected some people more than others negative peer pressure has increased drug and substance abuse in the coastal region peer pressure was shown to be a major predictor of licensed under creative commons attribution drug use in a research done by phyllys et al among young people in coastal region of kenya peer influence was shown to be responsible for 403 of the observed variation in drug use behavior similarly the researcher showed that peer pressure is a more significant risk factor for drug misuse than both family history and personal characteristics findings which confirmed the results in this current study according to the findings of this study 89 of the respondents indicated lack of awareness including lack of education on drug and substance abuse stigma and denial peer pressure limited access to information related to drug abuse and early exposure and misdirection as a cause of drug abuse ranking it at number 7 on the list of factors contributing to drug abuse in the region a study by stone et al conducted in the coastal region of kenya found out that majority of the youth who are drug users equated the lack of educational opportunities due to insufficient education funds to drug abuse where these respondents resorted to finding solace from the drugs to escape the reality of the situation this study also appreciated the unlimited time in the hands of these youth due to noncommitting educational life to the tendency of drug abuse this study revealed that majority of the residents in kilifi and mombasa counties do not have high level of education as a result the society does not have access to good jobs unfortunately the same society does not encourage children to get the rightfully required education to change the situation and this is an indication that things might be more dangerous in future according to the results as displayed in table 2 84 of the respondents indicated that easy accessibility of drugs is a major contributor this shows that the population in kilifi and mombasa counties can easily acquire drugs from the area the key respondents agreed with these findings and claimed that it is hard to regulate drugs in the region as a result the drugs end up being in the wrong hands the functionalism aspect of the society has been the basic form of operation of the drug barons in ensuring there is easy access of the drugs and in increasing the demands this is in accordance to functionalism theory which is based on the collaboration between different units of the society the drug barons work as one unit whose purpose is to supply drugs while on the other hand drug addicts acts as another unit of society the two units work together as there is existence of interdependence scenario the drug addicts depend on the drug barons as their suppliers while on the other hand drug addicts provide market to the drug traffickers it is the coexistence of both drug traffickers and drug addicts which makes drugs to be easily accessible the results in table 2 indicate that 82 of the household heads attribute adverse childhood experiences to drugs and substance abuse as outlined by the report outlines 10 categories of adverse child hood experiences including physical abuse emotional abuse sexual abuse physical neglect emotional neglect household substance abuse household mental illness parental divorce incarcerated household member and witnessing domestic violence since the society in this region has embraced a culture of drugs and substance abuse the children in the region have not been safe they have been witnessing drugs being used from the time they are young kids they have been abused by drug users as a result they suffer the fate of being victims as they grow up residences in both kilifi and mombasa counties have adopted the culture of drug abuse thus jeopardizing the future of the children in those two counties as suggested by the social learning theory an individual learns through observation as well as through imitation children in mombasa and kilifi county have been observing their elders abusing drugs something which they later tend to imitate as they opt to take it as hobby after a while those particular children end up becoming drug addicts as shown in table 2 81 of the household heads believe that social media is a factor that influences people into drugs and substance abuse social media has become part and parcel of daily life where people of all walks of life connect using social media sites irrespective of age gender or geographical distance this influences how people think act and behave despite the fact that the kenyan coastal region is extremely poor they can still have access to social media this is because in the current world even the cheapest phones allow the users to access the internet in addition as a result of business competition among network providers data bundles have become extremely cheap making them affordable to the poor social media is linked to drug abuse among some of the teens and youth in mombasa and kilifi different social media platforms glamorize drug and substance abuse where the vice is depicted as a relaxing and acceptable recreational tool advertisements have made smoking and drinking to be seen as normative activities by glorifying these practices thus subtly pressuring teenagers to experiment social media hurts mental health through the instillation of such feelings as sadness and loneliness together with depression mental illnesses have led to drug abuse furthermore social media has enhanced drug and substance abuse exposure hence the practice licensed under creative commons attribution social stigma leading to barriers to seeking help selfstigma and low selfesteem isolation and lack of support limited access to opportunities and reluctance to discuss prevention and treatment was discussed as a cause of drug abuse in this study table 2 indicates that social stigma ranks as number 11 with 76 of the household heads believing it is a cause of drugs and substance abuse in the region social stigma is best described as discrimination against a group or individual based on features that distinguish them from other people in this context social stigma refers to the negative association between persons suffering from drug and substance abuse disorders and their opponents who do not the stigmatizing attitudes beliefs and behaviors have combined forces in enhancing drug and substance abuse along the coastal region which refers to mombasa and kilifi stigma is understood to have several influencing factors and consequences from the societal level for people with behavioral health disorders related to drug abuse the hindrance from access to health care facilities for treatment has substantially promoted drug abuse in mombasa and kilifi discrimination against people with substance use disorders and drug addiction has blocked access to treatment thus promoting drug abuse the longstanding stigma in society and healthcare facilities is directly associated with increased drug abuse in both mombasa and kilifi the exposure to stigma has often made the victims turn to drug and substance abuse either as an initiation of the practice or promotion of the same thus social stigma is an important drug and substance abuse risk factor along the coastal region societal factors of moral decay including weakening of social institutions normalizing drug acceptance erosion of personal responsibility and weakening of community bonds table 2 shows that moral decay is the last main cause of drugs and substance abuse with 75 believing that the parameter influences whether the population abuses drugs or not moral decadence is greatly linked to drug and substance abuse in that one has the ability to lead to the occurrence of the other the two exacerbate each other as outlined by phyllys et al an example is the youth who engage in premarital sexual activities without the necessary precautions being employed the practice of such has been viewed as moral decadence in that a higher percentage of the youth have been exposed to the knowledge and guidance that they should engage in practices that improve on their lives rather than stall them most of these have ended up in distress with unplanned for pregnancies with others acquiring infectious diseases the demands that come about as a result of such actions have caused many of the youth to turn to drug and substance abuse as a way of escaping from their world of reality thus furthering the peril of drug and substance abuse in society types of drugs abused drug abuse is a significant issue in the coastal region of kenya with a range of drugs commonly abused understanding the different types of drugs being abused is crucial to developing effective prevention and intervention strategies in this section we will explore the various types of drugs that are commonly abused in the coastal region of kenya as found in this study highlighting their patterns of use and methods of consumption the findings are presented in table 3 the following types of drugs and substance abused in the coastal region were obtained from reliable literature such as kasundu et al 2012 mbuthia 2016 ongwae and oguya et al 2021 and used to get information from the study area in this study 99 of respondents confirmed that alcohol was the most commonly abused drug the study further revealed that there were various patterns of alcohol use including social drinking binge drinking and heavy drinking social drinking was reported as the most common pattern of use followed by binge drinking and heavy drinking the methods of consumption varied from drinking at home drinking at local bars and consuming illegal brews alcohol is among the most common drugs openly used in kilifi and mombasa counties as up to now it is still legalized this indicates that children do interact freely with alcoholics who live among them considering the hypothesis of social learning theory children in mombasa and kilifi county are always observing some members of the society abusing alcohol thus developing a desire to use it as a way of practicing what they observed with time the children become alcoholic at their tender age according to the household heads who participated in the study 98 of them reported that khat was a drug that was commonly abused in their communities ranking second among other types of drugs the patterns of drug abuse indicated that most users consume khat on a daily basis and the most common method of consumption is by chewing the leaves use of miraa was also linked to an increased risk of cardiovascular illness dental health issues and mental health difficulties according to a report by the ministry of health moh the report outlines that the drug is contributing to widespread poverty and stunting economic growth in the impacted areas hence the need for more stringent policy and regulations in comparison to the relaxed legislative laws seen in the country from the findings of the study 97 of the respondents admitted to using tobacco tobacco usage is widely accepted and celebrated in coastal communities where it has long cultural roots tobacco use is reinforced in part because of the social contexts in which it is often engaged in the high levels of stress and poverty prevalent in the area are also likely to contribute to the coping strategy of tobacco smoking the use of tobacco is characterized by frequent use with most respondents reporting daily experience of users the methods of consumption of tobacco vary with the majority of respondents smoking it in the form of cigarettes or using traditional pipes other methods of consumption include chewing and sniffing the findings of the study suggest that tobacco is a widely used drug in the coastal region and its use is deeply entrenched in the local culture the prevalence of tobacco abuse has been a center of focus for the who which outlined that 365 percent of kenyas population smokes cigarettes these findings agree with moh data which outlines that cigarette smoking is most common among men between the ages of 25 and 44 in addition tobacco smoking is a significant factor in the development of noncommunicable diseases in kenya according to research by the kenya medical research institute kemri the report highlighted tobacco use to be the second biggest cause of mortality from ncds accounting for 11 of all deaths in the country showing how critical it is to take immediate action to reduce tobacco usage in kenya the findings of the study revealed that bhang is the fourth most commonly used drug with 94 of the respondents reporting its use the drug is often consumed in various ways including smoking eating and drinking smoking was reported as the most common method of consumption eating and drinking were also reported where bhang was used as an ingredient in party cookies and pastry the drug was also infused in drinks like tea and other common favorite meals and snacks in the community smoking of bhang was the most common method of abuse and was reportedly carried out in open air in parties or in private bhang being an illegal drug in kenya means that the authority in kilifi and mombasa counties are expected to eradicate it however this tends to be impossible due to lack of proper functionality of the small units of the government in the region as per the functionalism theory aspect authority is made up of small units which are interdependent the units may include village elders assistant chiefs and chiefs among others due to lack of proper functioning of the small units comprising government in kilifi and mombasa county bhang has become a common drug being abused freely despite being illegal in this study heroin emerged as one of the most commonly abused drugs with 89 of household heads citing its use heroin is a highly addictive opiate drug that is derived from morphine a naturally occurring substance extracted from the opium poppy plant it is usually consumed through injection smoking or snorting the patterns of drug abuse and methods of consumption of heroin as outlined by the household heads in the coastal region suggest that most users inject the drug directly into their bloodstream where the powdery drug is first subjected to heating to melt it into an injectable liquid this method of consumption is particularly dangerous as it increases the risk of contracting bloodborne diseases such as hivaids and hepatitis c moh found that heroin use poses a significant threat to public health aga khan university found that poor socioeconomic position and low levels of education are significant predictors of drug abuse substance misuse was also more common among those who had experienced trauma or who were mentally unhealthy as per the research findings cocaine is a highly addictive drug that has been widely abused in the coastal region as shown by the findings of this study of the households surveyed 88 reported cocaine as a drug used in their communities ranking it as the sixth most abused drug in the region cocaine is typically snorted through the nose or dissolved in water and injected directly into the bloodstream cocaine trafficking and consumption are on the increase in east africa with kenya serving as a major transit and consumption country the regions rising middle class and the drugs image as a status symbol are the driving factors for the increased demand for cocaine licensed under creative commons attribution prescription drugs are another type of drug that is commonly abused in the coastal region according to the findings of our study the study revealed that 85 of the respondents reported the abuse of prescription drugs the respondents stated that these drugs were often obtained through pharmacies and hospitals using fake prescriptions or by visiting multiple doctors to obtain multiple prescriptions the drugs were then taken orally or injected and the most commonly abused prescription drugs were opioids benzodiazepines and amphetamines since the residents of kilifi and mombasa counties are relatively poor they cannot afford the drugs the addiction to drugs makes them to share injected blood a practice that endangers them to more health complications the person who manages to purchase the drugs allows his counterparts to remove blood from his body using a syringe and they inject it directly into their systems moh revealed that opioid misuse is the leading cause of americas drug abuse epidemic and that prescription medication abuse is a major contributing factor according to the health reports abusing prescription opioids may cause addiction overdose and death and is often linked to other types of substance misuse including heroin consumption it is unfortunate that the prescription drugs are prevalently used in the coastal region of kenya methamphetamine commonly referred to as meth is another drug that was found to be abused in the coastal region of kenya the study found that 80 of the respondents reported having used meth and it ranked eighth in the list of commonly abused drugs in the region methamphetamine is known for its highly addictive nature and devastating effects on the body studies have shown that longterm use of meth can lead to severe health problems such as heart disease liver damage and neurological damage methamphetamine is the second most widely misused substance in kenya behind only marijuana according a study by nacada the survey also found that meth usage has risen especially among the young in the coastal region of kenya the research also found that smoking snorting and injecting meth are the most common routes of administration in kenya effects of drugs and substance abuse the coastal community of kenya is beleaguered by a pervasive drug abuse dilemma manifesting in a comprehensive spectrum of ramifications that infiltrate diverse realms the deleterious impact of substance abuse is conspicuous in its profound influence on physical and psychological wellbeing evidenced through the heightened prevalence of ailments injuries compromised hygiene and malnutrition concomitantly a pronounced upsurge in depressive disorders anxiety and other psychopathologies underscores the toll exacted on mental health socioeconomic ramifications are equally discernible marked by an exponential surge in criminal activities concomitant with diminished productivity and a surge in healthcare utilization furthermore the scourge of drug abuse engenders a pervasive sociocultural disintegration encapsulating disrupted familial structures erosion of communal bonds and the attenuation of cultural identity stigmatization and moral degradation precipitate a precipitous decline in social cohesion driving unethical behavior educationally the consequences manifest as a decline in academic performance soaring absenteeism and a distressing surge in school dropouts consequently the collective fabric of this community once tightly woven now hangs precariously in the balance as the intricate repercussions of substance abuse continue to erode its fundamental underpinnings the results on the effects of drugs on the themes above were presented in table 4 in this study through an open ended question the household respondents were requested to include data on the effects of drug abuse that they have witnessed in the community the physical effects of drug abuse on the coastal community were one of the themes explored in this study according to the responses from the 384 household heads the topranking physical effect of drug abuse was illnesses with a response rate of 99 injuries poor hygiene and poor nutrition also had high response rates of 97 96 and 95 respectively the harmful physical repercussions of drug usage are a problem on every continent drug usage may lead to a number of health issues including those related to the heart and lungs the liver and kidneys and even infectious illnesses like hivaids hepatitis and tb accidents falls and acts of aggression are just some of the ways that drug usage may result in injury unodc found that drug usage was linked to a number of different ailments and injuries in their 2019 world drug report unodc has stressed the need for effective drug misuse prevention treatment and harm reduction initiatives the findings revealed that drug abuse has significant negative effects on the mental wellbeing of individuals in the coastal region the most reported mental effects were depression and anxiety both having a response rate of 98 following closely was mental illness which had a response rate of 96 and suicidal thoughts with a response rate of 95 it is evident that drug abuse has serious mental health implications in the coastal region of kenya the effects of drug abuse on mental health can vary depending on several factors including the type of drug used the frequency and duration of use the individuals overall health and their genetic predisposition to mental illness it is important to note that drug abuse can both exacerbate preexisting mental health conditions and contribute to the development of new ones one of the most common mental health issues associated with drug abuse is depression substance abuse can lead to chemical imbalances in the brain affecting neurotransmitters responsible for regulating mood drugs like alcohol opioids and stimulants can disrupt the brains natural reward system leading to feelings of sadness hopelessness and a lack of interest in previously enjoyed activities prolonged substance abuse can also damage brain cells and impair cognitive function further contributing to depressive symptoms anxiety disorders are another significant mental health consequence of drug abuse drugs that stimulate the central nervous system such as cocaine or amphetamines can trigger intense feelings of anxiety and paranoia licensed under creative commons attribution additionally individuals who abuse substances often experience high levels of stress due to the negative consequences associated with their drug use such as legal issues or strained relationships this chronic stress can lead to the development of anxiety disorders over time barasa et al observed that those with drug use disorders in kenya were more likely to experience sadness anxiety and suicide thoughts than the general population the unodc report also emphasizes the psychological effects of drug usage including the correlation between substance abuse and suicide ideation and action the report describes that 585000 people died in 2019 as a result of drug poisoning or overdoses those who are addicted to drugs were further reported to be six times more likely to attempt suicide than the general population depression and anxiety were also shown to be more prevalent among drug abusers to address the combined diagnosis of substance misuse and mental health issues who agrees with these results and suggests including mental health services into drug abuse therapy drug abuse is known to alter how someone reasons and this makes difficult for a drug addict to be in agreement with rest of the society however society being comprised of several units means it requires the contribution of each member functionalism theory is in agreement with the idea that every member of society should be working towards attaining the wellbeing of the whole society those who are mentally ill are a dysfunctional part of the society due to their poor reasoning and the fact that they do not work towards enhancing the society or their families the economic effects of drug abuse in the coastal community of kenya are significant according to the findings of this study in the survey of 384 household heads 97 identified increased crime as an effect of drug abuse while 96 cited lost productivity and increased healthcare costs increased unemployment was also reported as an effect of drug abuse by 95 of respondents these numbers indicate a strong consensus among the participants about the economic impact of drug abuse in the coastal region hospitalization expenses for drugrelated disorders were found to be significant with an average cost of ksh 52250 per hospitalization in research done by sambai et al in nairobi kenya approximately 5 of all hospital admissions were found to be drugrelated which accounted for a sizeable portion of the admissions overall according to the study hospitalization expenditures for drugrelated disorders are a major contributor to the overall economic cost of drug addiction according to research conducted by mboo et al in mombasa kenya medication costs were another significant aspect of health care costs associated with drug abuse in the coastal region of kenya as highlighted by the responses of household heads this shows that drug abuse not only impacts an individuals physical and mental health but also has a significant financial burden on households and the community in addition the kenyan ministry of health has published a guideline for the treatment of drug abuse that includes recommendations for the use of pharmaceuticals drug overdose poisoning and wound treatment all need expensive medicines some of which are included in the recommendation governmentrun public hospitals and dedicated drug treatment facilities make up the bulk of kenyas addiction care infrastructure methadone maintenance therapy which includes the use of medicine to assist patients in controlling their addiction and lowering the risk of relapse is the most prevalent treatment for opioid addiction in kenya lowincome families who may not have access to insurance or other types of financial aid may find methadone therapy too costly the monetary burden of drug misuse in kenya has been the subject of recent research drug misuse is related to significant healthcare expenses according to research by mwangala et al these costs include hospitalization medicine and rehabilitation services the research also indicated that incapacity and lost productivity due to drug usage may have considerable individual family and community economic costs according to an assessment by unodc the cost of drug usage in east africa is projected to be equal to 03 of regional gdp the cost of drug addiction treatment accounted for a significant portion of the overall economic burden of drug abuse this research revealed that heads of households in kenyas coastal area saw the cost of restoration as very high and our study confirms that perception the studys conclusions are consistent with those of the nacada which states that drug use has farreaching financial consequences for both people and society drug addiction causes higher healthcare expenses lower productivity and more crime drug usage may have farreaching financial consequences which include lower lifetime wages higher welfare and disability payments and lower tax revenues the effects of drug abuse on the social fabric of society are numerous and farreaching the breakdown of families and social ties has a ripple effect on the wider community people who abuse drugs often become isolated and marginalized leading to further social problems in addition to social effects drug abuse can also lead to physical and mental health problems the findings from the household heads in the coastal region revealed that broken families were the most significant social effect of drug abuse with a response rate of 75 this was followed by decreased social ties licensed under creative commons attribution with a response rate of 60 and stigmatization with a response rate of 50 loss of friendships had the lowest response rate of 15 teens as young as fifteen years of age have been exposed to the abuse of drugs and other addictive substances so being the case their indulgence in misdemeanors such as pickpocketing has furthered the development of drugrelated crimes early exposure to the abuse of drugs the influence of peers and idling has encouraged the development of this vice among teens consequently those caught have had to deal with the relentless mob in the name of justice while others have had to face the judges at the juvenile courts unfortunately these petty thefts arising from drug abuse begin at home where the teens steal money from their parents to enable them to gain access to drugs drug usage is linked to an increased likelihood of family disintegration and societal difficulties these results corroborate our own research showing that drug misuse has serious societal consequences such as shattered families and fewer friends substance misuse is undeniably a complicated problem that calls for a comprehensive strategy addressing the societal impacts of drug misuse requires interventions that prioritize prevention treatment and support for affected people and their families mwangala et al the findings indicated that 93 of the respondents observed that drug abuse had led to the loss of cultural norms making it the most prevalent cultural effect of drug abuse the second and third effects with an equal response rate of 90 were increased immoral acts and reduced respect respectively reduced cultural pride followed closely with 87 of the respondents expressing concerns over the issue these results highlight the gravity of drug abuse and the farreaching implications it has on the societys culture drug abuse is linked to an increase in criminal activity such as theft and violence which may cause a decline in social stability and community cohesiveness student drug abuse has been linked to lower academic achievement and fewer career prospects further demonstrating the negative effects of drug abuse on the educational system drug abuse can lead to social stigmatization where users are shunned by society and denied equal access to resources like housing and employment which further can lead to the dissolution of families due to increased domestic violence and child maltreatment breaking the fundamental community pillar which is a family as outlined by who drug abuse has farreaching cultural repercussions including discrimination decreased productivity and the collapse of social institutions drug misuse weakens the moral fiber of a society and weakens the ties that bind its people together loss of cultural legacy diminished selfesteem and increased criminal behavior are only some of the cultural repercussions of drug usage as noted in a report by samhsa the cultural repercussions of drug misuse among indian teenagers were also studied by harini and krishnan according to the studys results drug abuse causes people to lose touch with who they are and causes them to abandon cultural norms like respect for elders and traditional religious observances these results are consistent with the present studys findings suggesting that the cultural repercussions of drug misuse are felt across the world the results of the study indicated that academic effects are ranked the 6 th with 86 agreeing that drugs and substance abuse affect poor performance 84 relating the drug menace to absenteeism while 80 agreed that drugs and substance abuse lead to school dropout first drug and substance abuse impair cognitive development thus reducing academic excellence among students substance abuse therefore reduces academic achievement and disrupts academic progression a students performance in school is affected because their ability to memorize things and concentration span is reduced the poor performance results from a lot of time being spent nursing the problem of drug and substance abuse instead of placing the focus on school work research reports have supported the notion that drug and substance abuse is undeniably linked to poor academic performance based on how much the menace continues to prevail in the coastal region this case refers to mombasa and kilifi other than affecting academic performance at an individual level drug and substance abuse has interfered with academic excellence for other students in some cases those with substance use disorders have posed a mighty challenge to their classmates considering that the type of drug they put into use includes marijuana which interferes with shortterm memory learning and psychomotor skills they are likely to interfere with the conduciveness of a learning environment such as a class the students may be involved in violent and aggressive behavior which will likely minimize how conducive the classroom atmosphere is for learning consequently they present obstacles to learning for their classmates drug abuse among teens and other schoolgoing ages such as those at the college and university level has tremendously affected their academic performance the susceptibility of these groups to drug abuse has aggravated the matter with the increased use of both legal and illegal drugs the lack of knowledge on the risks licensed under creative commons attribution associated with drug abuse failure to take action upon the raise of concerns and gross ignorance of groups such as parents students and schools leadership has led to serious problems in the learning institutions with the dominant one being deteriorated academic performance as such drug and substance abuse has negatively affected academic outcomes in both mombasa and kilifi iv conclusions recommendations conclusions this paper has given the results on nature of drugs and substance abuse in kilifi and mombasa counties the paper has presented results on the nature of drugs and substance abuse using parameters on causes of drugs and substance abuse the types of drugs abused the prevalence of drugs and substance abuse and the effects of the menace to the community the study found that drug and substance abuse is a significant problem in the coastal region of kenya affecting individuals across all age groups and socioeconomic backgrounds the most commonly abused drugs were alcohol tobacco bhang and khat heroin cocaine prescription drugs and methamphetamine the abuse of drugs was central across all the age groups including adults and children abuse was prevalent among the youth particularly those who are unemployed school dropouts or living in poverty females were less frequent abusers than males but the abuse was also common amongst females with complimenting factors such as poverty depression and other underlying conditions catalyzing their indulgence in the malpractice the abuse of drugs was soared across the socioeconomic ladder and having excess funds and limited funds were contributing factors to the abuse recommendations the results of the study indicate that most of the commonly abused drugs are in high demand thus increasing supply notably most are smuggled across borders by traffickers the study recommends strict border control adequate provision of security personnel at the border posts and adoption of new technologies to aid in surveillance and monitoring and tracking of the smugglers

drug and substance abuse has become one of the looming humaninduced disasters globally making it a profound concern among the comity of nations owing to the significant detrimental effects it has in almost every aspect of life and development in kenya it has become one of the major social catastrophes with the commonest and most easily identifiable manifest in public health specific objective of the study was to examine the nature of drug and substance abuse in selected counties in the coastal region kenya the study was guided by the social learning theory and functionalism theory the study was further underpinned by the interpretivism approach the study used descriptive and evaluative research designs with data collected through interviews and focus group discussions the study was conducted in kilifi and mombasa counties data was collected from 552 respondents who included 384 household heads 20 victims 2 county education officers 2 county commissioners 2 county health officers 70 administrative chiefs 102 village elders 9 head of nacada officers and 8 religious leaders the study revealed that drug abuse is a significant problem affecting individuals of all ages and socioeconomic backgrounds commonly abused substances include alcohol 99 383 khat 98 378 tobacco 97 376 cannabis 94 364 heroin 89 341 cocaine 88 337 prescription drugs 85 326 and methamphetamine 80 307 both males 75 289 and 25 95 females engage in drugs and substance abuse the main causes of the menace are unemployment 99 380 poverty 98 376 mental illnesses 97 373 and curiosity and experimentation 96 370 the study recommends strict border control adequate provision of adequate security personnel at the border posts and adoption of new technologies to aid in surveillance and monitoring and tracking of the smugglers

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societal provisions for male victims of domestic violence and inhibit the willingness of same to seek social welfare services thus the social welfare system in america at federal state and local levels has operated within a cultural tradition which sees women as victims and men as perpetrators of domestic violence commensurate with such traditions women in need have qualified for various social welfare services less available to men this began in 1935 when democrats founded the social security act which was mainly a means to assist needy elders but included a provision for women unable to sustain themselves without support of welfare services the social security act offers a dramatic illustration by which social welfare disparities between men and women can be exposed and investigated aid to families with dependent children and the maternal and child health program benefitted women in need without public opposition because said services reserved for women conformed to cultural tradition hence feminization the prestige brought by the federal government in funding social welfare services comes from a culturallymotivated public and political intervention by its own policies and actions government then influenced the institutions of social welfare to the extent that services now show less consideration to needy men this is so despite evidence acknowledging males in need resulting in the feminizatiobn of poverty subsequently while the feminization of poverty did not result in less attention to poor men the feminization of social welfare has resulted in less attention to male victims of domestic violence according to pearce and northrop the feminization of poverty illustrates an existing bias against women andor femaleheaded households subsequently there exists a disparity in the levels of poverty between men and women this feminization of poverty may also account for the increasing impact of sex roles as a determining factor in both perceived rates of poverty and the ability of male victims of domestic violence to access social welfare services because of feminization the evidence of men victimized by domestic violence has not been sufficiently addressed in public discourse efforts on the part of government less inclined to assist male victims of domestic violence are embraced by the most politically conservative members of society those who object do so only regarding which programs serve which population and how much they should cost the feminization of social welfare as a cultural tradition and its implications for male victims of domestic violence are seldom acknowledged the intent of this paper is to illustrate visavis domestic violence the impact of feminization upon the provision of social welfare services as pertains to male victims while feminization will be addressed in the context of domestic violence it is suggested that feminization permeates all aspects of the social welfare system because it is commensurate with the cultural traditions of western civilization feminization herein is thus defined as a social institutional and political motivation to sustain objectives however unintended counter to assisting males in need by addressing feminization of social welfare through domestic violence this paper will expose the disserving characterizations of an otherwise vulnerable population of men who by cultural tradition are designated less entitled the vulnerability of these men provides a rationale for the construct of a more scientific andor technological social welfare paradigm to objectively allocate social welfare resources the following will facilitate comprehension of the circumstances the feminization of social welfare a brief overview of domestic violence male victims of domestic violence and solutions to cultural tradition the feminization of social welfare the feminization of social welfare illustrated by domestic violence as vehicle is a longstanding tradition embedded in the cultural perception of women as caregivers in western patriarchal societies such as the us women as caregivers are assumed subject to the authority of men in fact women as caregivers are no more or less significant to caregiver roles than are men to whose authority they are assumed subjected whats more those among decision makers who reinforce feminization in the context of cultural traditions are more often male judges male politicians male police officers and male social workers employed in the social welfare system thus male social workers who should oppose patriarchy are no less culpable than women in sustaining it their inability to acknowledge male victims of domestic violence is attributed less to their personal preference and more to traditions of the western patriarch subsequently by western patriarchal tradition submission is believed of women and aggression is believed of men social welfare programs and services are then necessarily feminized because the benefits of patriarchal chivalry have been the traditional cultural domain of women yet according to mcneely and robinsonsimpson scholarly literature published in respected peerreviewed journals consistently illustrates that men in the us are equally as likely to be the victims of domestic violence by women as are women by men the feminization of social welfare is recapitulated among male social workers who provide services to women clientele according to hall male social workers who do not actively oppose male patriarchy are in fact breeching the nasw code of ethics halls insistence that male social workers actively oppose patriarchy leaves little doubt as to its existence in black males left behind referring to pouncys contention that opposition comes from advocates for lowincome women the feminization of social welfare is then institutionally sustained as standard evidence exists in gains made by low income women and is suggested in their higher earnings brought by welfare reform efforts according to haskins both employment and earning gains for women during the clinton administration were much stronger than for similarly economically situated men voyce investigated the significance of cultural tradition in male patriarchy relative to domestic violence subsequently it was determined that male patriarchy as a cultural tradition is also manifested in affairs of the state relative to its administrative apparatuses of power contributing to feminization said manifestation is apparent in both legal and illegal forms of male power thus wealth as a male cultural tradition is sustained as a critical form of governance such dynamics operate similarly to sustain the perception of women as exclusive victims of domestic violence it is in essence the means by which the feminization of social welfare is normalized institutionally the aforementioned pertaining to the feminization of social welfare is normalized not only by the cultural traditions of its patriarchal institutions but by the associated social welfare scholarship as well that normalization is evident in the databases where feminization by cultural tradition has dominated scholarly literature this otherwise obvious assumption is not the least subject to challenge as indicated by one of social welfares most esteemed sources the social work abstracts database the social work abstracts database contains peerreviewed papers published for years 1964 to 2010 the following terms alluding to feminization as cultural tradition were searched by the author men women mothers fathers husbands and wives the results indicate that papers published on men were only 52 of those published on women papers published on fathers were only 41 of those published on mothers papers published on husbands were only 80 of those published on wives such disparities reflect cultural traditions which influence social welfare agencies to prioritize services and resources commensurate with the feminization of social welfare not exclusive of domestic violence a brief overview of domestic violence a brief overview of domestic violence can also be gleaned from the databases pertaining to papers published one of the largest data bases is proquest which contains scholarly papers written from 1894 to 2010 to assess the issue of domestic violence the author searched the following terms male batterer female batterer male perpetrator female perpetrator male victims female victims women victims men victims violent men violent women the results are presented in table format according to table 1 papers pertaining to female batterer were 5 of those pertaining to male papers pertaining to female perpetrator were 52 of those pertaining to male papers pertaining to male victim were 49 of those pertaining to female papers pertaining to men victim were 6 of those pertaining to women victim papers pertaining to violent women were 22 of those pertaining to violent men the social work abstracts is a database aimed specifically at the social work professions it contains scholarly papers published from 1964 to 2010 to assess the issue of domestic violence the author searched the following terms wife victim husband victim male batterer female batterer the results are similarly presented in table 2 according to table 2 papers pertaining to husband victim were 58 of those pertaining to wife victim papers pertaining to female batterer were 51 of those pertaining to male batterer while most victims of domestic violence are women those prone to acts of domestic violence cannot be universally identified as male the community appearance status and demeanor of perpetrators regardless of sex make them appear personable and loving to their partner and family members their acts of domestic violence may occur in private concealed from public display they may act out physical violence against their partner by injuries easily hidden such as scars not normally visible due to clothing or injuries which do not require medical attention what qualifies such assaults as domestic violence is that they do not occur by accident perpetrators do not act solely out of stress excessive drinking or drug abuse domestic violence is in fact committed for purposes of control by one partner of the other the ensuing level of violence may escalate until the desired control outcome is reached failure to reach such an outcome may conclude in homicide found 84 of american families do not engage in domestic violence of those 16 who are violent most engage in some form of slapping shoving and grabbing approximately 34 of about 18 million engage in extreme forms of domestic violence including kicking punching or using a weapon straus and gelles further contend that 188000 women a year are subjected to violence severe enough to warrant medical attention while that number is extreme it is not in the assumed millions that some have reported other studies pertaining to domestic violence include that published by oleary barling rosenbaum and tyree it involved 272 couples in a longitudinal study of early marriage results indicated that 44 of the women compared to 31 of the men were physically aggressive after 18 months 36 of the women and 27 of the men reported being physically aggressive after 30 months of marriage investigators found no significant differentiations in physical aggression between men and women however at each interval women were in fact more aggressive than the men to whom they were married these various forms of aggression included pushing shoving and slapping by the use of conditional probability analysis and given the likelihood of aggression at 30 months and before marriage and at 18 months after marriage scores were 72 for women and 59 for men male victims of domestic violence in 2009 a male cheerleader at the university of missouri was brutally attacked by two players on the womens basketball team the incident was preceded by the cheerleaders decision to conclude a team party being held at his residence he thus requested that guests vacate the premises however as reported by the local riverfront times newspaper the two noted women players unprovoked began a violent assault upon the male cheerleader they beat and punched him about the facial area until they broke his nose and injured his eye partygoers attempted to restrain the assailants but were unable to do so both players were suspended from the team and were not prosecuted twelve percent of homicides in the us are committed by women and 12 of the serial killers are women they are likely to murder a spouse 19 of the time a friend or acquaintance 17 of the time and a boyfriend or girlfriend 10 of the time whats more the rationale for women who kill is money 41 of the time when an abused woman murders her husband or partner drugs are commonly involved as party to feminization of social welfare the government has contradicted itself considering its own research according to the justice department 41 of spouses murdered were men another study conducted by mann at the department of criminal justice indiana university at bloomington indicates that no more than 59 of women who murdered their husbands claimed selfdefense of those about 30 had been previously arrested for violent crimes furthermore according to the justice department of those women who murdered their husbands 129 were acquitted of those men who murdered their wives only 14 were acquitted whats more those women found guilty of murdering their husbands received an average sentence of six years while their male counterparts received 17 years for murdering their wives some of the most highly respected among public officials are no less inclined to the feminization of social welfare which views women as victims such as donna shalala recent secretary of health and human services the secretary reported that 4 million women are battered in a given year by their significant male other she does not report the source of her data but her stated statistics are in conflict with official documentation according to a 1993 harris poll two percent of the 2500 women interviewed reported being kicked bit hit with a fist or some other object if that number is calculated by the approximately 55000000 women associated with a significant male other the result is 11 million subsequently there is an excess of 29 million reported the only reasonable explanation might be that women who reported being pushed grabbed or shoved were considered having been battered despite this fact social welfare professionals as well as the lay public do not accept that women are equally the perpetrators of domestic violence as are men likely due to cultural norms furthermore professionals and the lay public refuse to accept that such men can be the victims of domestic violence as often as are women the cultural belief among americans is that men being more aggressive than women are prone to violence despite evidence to the contrary women who commit domestic violence against men encounter a double standard when compared to men who commit domestic violence against women much of it is on display in the literature consisting of investigations exclusively by various social science scholars bohannon dosser and lindley collected a sample to assess domestic violence between husbands and wives their results indicate that of 94 military couples 11 of wives and 7 of husbands were engaged in behaviors considered physically aggressive as reported by the wives ellison barkowski and anderson found an association of religion with incidents of domestic violence their subjects were selected from the first wave of the national survey of families and households it included 2420 women and 2242 men the selfadministered survey results suggested that women were significantly more likely than men to act out violent behaviors toward their male partners as per religiosity regular attendance at religious services is inversely associated with domestic violence for both men and women headey scott and de vaus conducted a study of domestic violence in australia for data they used the international social science survey australia 199697 their sample consisted of 1643 subjects each answered questions pertaining to their experiences with domestic violence within the last 12 months investigators found that 57 of men and 37 of women reported being the victims of domestic assaults as pertains to physical injuries women were found to inflict bodily harm at least as often as men statistically 18 of men and 12 of women reported that the bodily harm they sustained required firstaid lastly 15 of men and 11 of women reported that their injuries required treatment administered by a health care professional kessler molnar feurer and appelbaum investigated mental health patterns relative to domestic violence in the united states their sample consisted of 3537 subjects of these 1738 were men and 1799 were women these data were extracted from the national comorbidity survey which is a nationally representative survey conducted between the years of 1990 and 1992 all who qualified were married or cohabitating males and females between the ages of 1554 years the findings suggest that 174 of women and 184 of men reported being the victims of physical violence at the hands of their current spouses andor partners mccleod investigated domestic violence against men said investigation was based upon an analysis of official and national victimization data it consisted of 6200 cases of spousal abuse in the detroit area from 19781979 findings indicate that men resorted to weapons 25 of the time women on the other hand resorted to weapons 86 of the time as a result 74 of men incurred injuries and accordingly 84 required medical attention subsequently mccleod determined visavis empirical data that men are more often injured and are injured more seriously than women mcneely cook and torres set out to determine whether domestic violence is a gender issue or a human issue they contend based upon empirical evidence that domestic violence is in fact a human issue and not due to the commonly held belief that it is a gender issue the confusion may be a result of mens legal and social defenselessness mechem shofer reinhard hornig and datner investigated the history of domestic violence involving male patients seen at an urban emergency department their sample was compiled during a 13week period at a philadelphia emergency clinic investigators found that 126 of 866 men were domestic violence victims citing secondary data investigators acknowledged that 144 of women treated in similar emergency departments had been victims by juxtaposing nonvictims victims were more likely to be single younger and identified as africanamerican by reference to assaults 48 of males contend that they had been kicked bitten choked or punched by a female partner another 37 confided that they had a weapon used against them lastly ridley and feldman reported on female violence against males in a domestic context their sample consisted of 153 female volunteers they were administered the abusive behavior inventory findings were that 673 of subjects admitted to at least one event of violent behavior conducted by them personally in the past 12 months the most common forms of violent behaviors consisted of pushing shoving and holdingdown the next most common form of violent behavior consisted of slapping hitting and biting while the aforementioned evidence of domestic violence by women aimed at men is dramatic it is also a factor of entertainment according to marcus the recent television hit series jersey shorepromoted violence against men during one of its highly touted episodes one of the female characters named j woww smacked the situation in a later episode a drunken angelina struck pauly d in the facial area whats more in response to a previous episode where a male character struck a female character the administrators of the show featured a public service announcement abhorring domestic violence in response this show is aired by the mtv cable station as a consequence of what it broadcasts violence against men by women is tolerated while violence against women by men results in a public service announcement jersey shore is not the exception another mtv series which tolerates violence against men is teen mom one of the central characters amber on more than one occasion has acted out violence against gary who is the father of her child another teen mom character farrah was reportedly assaulted by her mother debra while the assault was not caught on camera much of the episode focused on farrahs followup with an attorney to press charges against her mother and her referral for therapy to cope in response to farrah being assaulted mtv broadcast a number for a domestic violence hotline when women were victims of domestic violence as was farrah the cable station acted when men such as gary were assaulted by women the cable station has yet to respond with a public service announcement objecting mtvs reality series have left much of the public confused it would appear that it has embraced a double standard that is domestic violence is permissible as long as it is female to male subsequently if the gary character had struck amber it is likely that the police would have been called and shortly thereafter the station would have aired a psa against domestic violence failure to do so when men are the victims of domestic violence is a disservice to all victims of domestic violence regardless of sex solutions to cultural tradition by definition culture includes lifestyles customs art religion language values and behavior associated with a particular group at a particular point in time culture enables life by empowering the weak to be collectively strong and thus integrating large numbers of people on the basis of a shared commonality culture does not require legal sanction in order to be effective but more often than not in advanced technological societies culture influences the structures of litigation in actuality culture is a catchall term which appears to exclude very little quality of life matter however for comprehending the feminization of social welfare relative to domestic violence interested parties must consider the associations of culture with patriarchal tradition similar to culture tradition in general includes a set of interrelated phenomena through which reality is created communicated and by social welfare administrated social welfare relevant phenomena include methods of service demographics of personnel perspectives standards and ways of relating in a cultural context when such phenomena operate in conjunction they come to represent a significant aspect of what is assumed in the us to be the most prudent operation of social welfare services which under the current circumstances enables feminization the application of tradition gains validation through correlation to several attributes it gives credibility to the existence of culture for fashioning the delivery of services and its demographic priorities the traditional social welfare modus operandi emphasizes values and norms of the patriarch which establishes women as victims of domestic violence and men as perpetrators of same without overt formal andor informal communication social welfare by cultural tradition then prioritizes victims of domestic violence according to the standards of feminization the delivery of services and distribution of social welfare resources become less amenable to scientific facts which conflict given the existence of male victims within social welfare institutions male victims of domestic violence are then located in opposition to similarly victimized women resulting in unnecessary and disserving tension said tension discourages focus on the elimination of domestic violence in toto for focus upon women as the defining and most urgent victims of the problem solutions to cultural tradition aimed at eliminating male victims of domestic violence must necessarily begin with acknowledgement of the characteristic warning signs and symptoms no partner involved in an intimate relationship regardless of their sex should submit themselves to living in fear of their significant other whether legally joined or not when the warning signs or violence becomes apparent victims should not hesitate to terminate the relationship or seek immediate help according to domesticviolenceorg when attempting to escape the risks of domestic violence the following are things one needs to think about 1 having important phone numbers nearby for you and your children numbers to have are the police hotlines friends and the local shelter 2 friends or neighbors you could tell about the abuse ask them to call the police if they hear angry or violent noises if you have children teach them how to dial 911 make up a code word that you can use when you need help 3 how to get out of your home safely practice ways to get out 4 safer places in your home where there are exits and no weapons if you feel abuse is going to happen try to get your abuser to one of these safer places 5 any weapons in the house think about ways that you could get them out of the house 6 even if you do not plan to leave think of where you could go think of how you might leave try doing things that get you out of the housetaking out the trash walking the pet or going to the store put together a bag of things you use everyday hide it where it is easy for you to get 7 going over your safety plan often the aforementioned is advised regardless of race sex sexual orientation socioeconomic and marital status solutions to the cultural traditions of domestic violence must include redefining culture and its appropriate place in the conduct of social services in the face of two powerful barrierstraditionalism and the status quothis characterizes the reduced viability of the attempt culturally diverse scholars stress the process of selfacknowledgment and the proclamation of existence as the first critical step in personal and later social acceptance of what is different for male victims of domestic violence this simple proclamation by social welfare personnel would be a revolutionary act in its repudiation of a culturallyimposed limitation upon access to programs and services male victims of domestic violence are unique in that their defining difference is an experience with which the mainstay of social welfare professionals including both male and female social workers assigned to domestic violence lack affinity since males in need can be identified by their appearance their access to domestic violence services may be unnecessarily complicated for traditional cultural reasons as a result to the degree that social welfare and who has access to services is a culturally constructed phenomenon victimized males in need require advocates in all areas whose sole purpose is problem resolution conclusion according to kosberg men are portrayed in social welfare literature as gay or in an otherwise negative context women are disproportionately portrayed as victims powerless vulnerable and disadvantaged due to the sexist and racist efforts of men such characterizations impose upon the public perception of male victims of domestic violence despite scientific evidence to sustain their plight therefore relative to feminization much of the available literature on domestic violence has justifiably emphasized the needs problems and empowerment of women to the exclusion of equally justifiable male victims such concerns for women are no doubt a legitimate issue however the extent of such concern results in the feminization of social welfare which accommodates an imbalanced frame of reference to a serious social pathology profession according to merriamwebster is defined as a calling requiring specialized knowledge and often long and intensive academic preparation the feminization of social welfare in the us extends from the traditional cultural norms and preferred values of society indeed social welfare personnel such as social workers are members of a values profession not irrelevant to cultural traditions in the conduct and delivery of services nationwide in fact some have referred to the us as a christian nation not irrelevant to the operations of social welfare as an institution social welfare was in fact subject to the nations forefathers who understood clearly the potential for abuse when cultural traditions in the form of religion operate in an otherwise multicultural multiracial society whose fundamental creed is freedom thus by official decree they took action to insure that no one religion philosophy or other statesponsored value system would prevail that belief was sustained by many operatives in the scientific community who felt imposed upon by value systems in the conduct of their work they preferred separation of culture and services science in an effort to insure attentions to need would prevail independent of cultural and political influences unfortunately such influence has not discouraged the oversight of male victims subjected to domestic violence the feminization of social welfare thus remains an impediment to the elimination of domestic violence and validation of rigorous scientific discourse in the aftermath of their advocacy for male victims of domestic violence in need both male and female social workers are subjected to unnecessary stress in attempts to maintain coherence and direction thus when social welfare institutions contradict science and cannot reach consensus about the priority of programs and services neither men nor women victimized by domestic violence can be optimistic about the future an effective tool is application of more objective policy models which better locate the role of cultural traditions in the perception and attention to all victims in need moving beyond the feminization of social welfare as pertains to domestic violence can be accomplished by the recognition that cultural tradition should not be the sole determinant of services that is as an institution social welfares attention to those in need must be considered by development of a social welfare technology while this technology may operate within a cultural context the resolution of problems must be dictated by scientific objectivity recognized schools of thought suggest that scientific objectivity relative to technological competence means the capacity of social workers within the social welfare system to execute a particular task free of cultural bias this simple definition becomes obsolete when applied in the absence of science leaving feminization of social welfare to fill the void furthermore as per the feminization of social welfare technological competence enables services because the variations in tasks are made more consistent and intelligible commensurate with differing treatment methodologies and demographic categories including sex whereas decisionmaking ability treatment modality and knowledge base as an extension of culture is important none of these as a single criterion reign sufficient without the benefits of scientific objectivity however considered in conjunction with scientific objectivity they can potentially comprise social welfares professional technology cynicism and burnout stem partly from people loyal foremost to culture and tradition it is a common event for those employed in social welfare fields including social workers who are often overworked and underpaid women in particular who clearly understand the urgency of domestic violence and who are not influenced by its feminization in their view of male victims are most at risk for such burnout their struggles more often take place within an environment where agencies do not share a common vision about the problems of society thus by necessity in resolving the problem domestic violence most be moved from a cultural to a social justice context

as pertains to feminization of social welfare the inability to acknowledge male victims of domestic violence is attributed less to personal preference and more to cultural traditions of the western patriarch yet according to scholarly literature men in the us are equally as likely to be the victims of domestic violence by women as are women by men solutions to cultural tradition aimed at eliminating male victims of domestic violence must necessarily begin with acknowledgement of the characteristic warning signs and symptoms moving beyond the feminization of social welfare as pertains to domestic violence can be accomplished by the recognition that cultural tradition should not be the sole determinant of services an effective tool is application of more objective policy models which better locate the role of culture in the perception and attention to all victims in need

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introduction the education sector is currently undergoing a massive and significant transformation comparable to the 19th century dawn of universal schooling this transformation is underpinned by technology advancement particularly in the form of elearning technologies and technologyenhanced learning whilst the future of elearning is promising it still needs to overcome reputational and quality hurdles to prove itself in the context of this study learning technologies refer to technology innovations that are already mainstream and currently being used to support learning particularly in higher education elearning refers to the use of ict in the enhancement and support of learning and teaching in education kalpa publications in computing volume 12 2019 pages 123131 proceedings of 4th international conference on the internet cyber security and information systems 2019 tel extends the application of elearning and includes the enhancement of classrooms through learning with technology the use of technology by higher education institutions in improving outcomes still remains a challenge there is a gap in how pedagogical innovation combined with these technologies affect the future of society furthermore institutions are challenged with harnessing technology power as a means to accelerated access to education and improved overall success leadership plays a critical role in the acceptance adoption and continued use of learning technologies in higher education institutions akcil aksal mukhametzyanova and gazi identify technology selfefficacy and acceptance in leadership as influential in driving digital citizenship in the education system similarly bälter identifies leadership that instils cooperation between crossdisciplinary areas as critical in improving technology acceptance in higher education a leadership that develops an innovation driven culture and infrastructure also supports adoption of elearning within the organisation various trends have shaped learning technologies in the past five years the wider adoption of massive open online courses open educational resources and learning management systems have propelled elearning to be one of the main agenda items for higher education leadership moocs are massive in terms of number of concurrent learners they accommodate usually for free and delivered online oers seek to increase public access to educational resources through open license andor free access an institutions existing infrastructure expectations from students and skillsattitudes of staff members are some of the main drivers of elearning adoption in higher education institutions in the next five years and beyond leadership will continue to play a role in the adoption of learning technologies within higher education institutions amongst others learning technologies will be driven by greater adoption of adaptive learning microlearning and gamification these are complex interventions that need to be properly thought through by leadership this paper proposes a conceptual model for the adoption of learning technologies in higher education institutions literature review adoption of technology has traditionally been slow in the higher education sector some of the factors that hinder elearning adoption include existing infrastructure anticipated learner needs and capabilities of staff on the other hand drivers such as competitive market places the need to reduce costs against the backdrop of increasing student expectations are driving the need for technology adoption in order for institutions to be sustainable and scale up in the digital age inclusion of innovation in the organisation strategy is crucial to justify the need for better framework for adopting innovations this study illustrates recent elearning developments that are impacting the higher education sector from the literature reviewed six emerging technology themes are appearing more consistently than others these are adaptive learning microlearning gamification learning analytics artificial intelligence and ubiquitous learning this section discusses these themes and their potential impact in higher education adaptive learning peoples learning styles differ whilst some might find technical concepts easy to grasp others might be challenged by the same material adaptive learning intends to personalise the learning experience in order to cater for an individuals learning style learning environments that take learning style influence yield positive achievement results for students isaías predicts that by 2020 adaptive learning will be a leading strategy driver in delivering personalisation whilst adaptive learning receives positive reviews from targeted research respondents its application on assessment is still at infancy stage microlearning microlearning breaks up learning material into bitesized chunks in an effort to help the learner achieve a specific objective microlearning provides learnercentricity accessibility while reducing the time it takes to put together learning material the advantages of microlearning include little effort required from learning sessions high potential for engagement and informal learning context microlearning has the potential to increase retention of information by 20 microlearning has limitations such as its unsuitability in complex learning scenarios as it inherits from an informal disposition it can be easily perceived as less impactful gamification gamification in learning refers to the application of gaming techniques in support of different activities and behaviours in the learning experience gamification enhances student engagement on learning content that leads to anticipated behaviour change using behavioural science principles gamification increases the motivation and involvement of users in learning content popular affordances where gamification has been applied include achievementprogression immersion and social cooperation features one of the drawbacks of gamification is the cost of developing effective gamified content learning analytics using a wide range of learner data and information learning analytics aims to provide deep insights into learner behaviour progress and learning contexts with the aim of improving learning learning analytics enable teachers to understand their learners better resulting in better usage of already stretched resources implemented successfully learning analytics are expected to make contributions in quality improvement and assurance increasing student retention rates improving assessments and enabling other elearning innovations learning analytics have a long way to go gašević dawson and siemens argue that for learning analytics to be effective it needs to leverage off existing learning and teaching body of research knowledge also ethics and privacy concerns are considerations in the future of learning analytics drachsler and greller highlight data misuse cyberattacks and commercial interests as ethics and privacy concerns to be considered artificial intelligence in learning ai algorithms are a promising avenue in the delivery of individualised instruction whilst ai tutoring is helping to reduce the burden on teachers by helping in assessments and providing student support ai will also play a role in selflearning interventions that will play a role in personalising the learner experience isaías predicts that ai will be widely implemented for the mainstream users within this decade ubiquitous learning ubiquitous learning enable the learning process to transcend geographic and time limits allowing students to learn anywhere and anytime mobile learning is experiencing unprecedented growth that is fuelling ubiquitous learning advancing mobile technology and the increasing number of students using mobile devices will make mobile learning a key element of education strategy for higher education institutions this list of technologies is not exhaustive but merely highlights some of the key technologies that are shaping the industry now other technologies such as virtual and augment reality internet of things and social learning are also worth noting however due to space limitations this paper does not cover these technologies the next topic discusses the model and framework that support the adoption of these technologies theoretical foundation this section discusses the theoretical foundations that have contributed to the proposed conceptual model in this study there are various theories that are useful in the study of learning technology adoption such as the innovation diffusion theory the technology acceptance model the united theory of acceptance and use of technology and the concernsbased adoption model the transformative framework for learning innovation and the emerging learning technologies model are more specific to the emergent dimension of learning technologies and thus best suited for this study the transformative framework for learning innovation the transformative framework for learning innovation is a strategybased conceptual model that considers a relationship between an institutions internal resources and skills against its environments opportunities and risks tfli advocates for innovation choices to be based on the ability of technology to meet institutional objectives using four quadrants tfli categorises technology adoption strategies according to marketmission objectives and newness of technology error reference source not found outlines tfli and its four quadrants according to salmon quadrant 1 leverages an institutions current core infrastructure and processes by infusing them into new teaching and learning opportunities whilst this is a slow evolutionary approach it increases pedagogical soundness this quadrant can ensure equal distribution of services and learning experiences for every student irrespective of location quadrant 2 continues leveraging current technologies and pedagogies but seeks to address new and different learning and teaching opportunities this quadrant allows the institution to significantly increase uptake and expand geographically it also creates a possibility for full digital delivery or onlineonly platforms quadrant 3 addresses existing missions by employing new technologies most of these technologies are not necessarily developed for teaching and learning but they get adapted to this environment others such as moocs and oers are built for educational use cases from the ground up quadrant 4 pushes the boundaries by addressing new opportunities through employment of new ideas riskier technologies and new types of students this quadrant extends the biggest potential for placing the institution on the digital map on the other side this quadrant requires a technology leader approach technologies such gamification machine learning augmented reality currently reside in this quadrant emerging learning technologies model using the emerging learning technologies model isaías claims that emerging technologies should be selected and implemented to attain five core characteristics of learning personalised ubiquitous collaborative lifelong and authentic there is a growing demand for personalisation in learning becker et al identify ubiquitous collaborative and learning as key drivers in learning lifelong learning also continues to be a growing trend error reference source not found breaks down the technologies that make up eltm the list of technologies is not exhaustive they rather present scaffolding capacity for further learning attributes figure 1 the transformative framework for learning innovation the framework and model discussed above provide a legitimate context from which higher education institutions can make meaningful adoption decisions however these tools come from disparate viewpoints the following section proposes combining the framework and model into a comprehensive model the conceptual model the proposed conceptual model super imposes eltm on top of tfli this approach provides higher education institutions with a clearer context of the types of technologies to consider against organisational contexts andor objectives the model follows the same quadrant principle as tfli it then meaningfully allocates the core characteristics and respective technologies identified by eltm into the quadrants this significantly improves understanding for decision makers whilst tfli provides a quadrant approach upon which to classify technology types by maturity and organisational missioncontexts eltm provides a context that is driven by learning objectives combining these two approaches provides a logical approach for higher education institutions to address organisational strategic and learningspecific dimensions in a coherent format error reference source not found outlines the proposed conceptual model quadrant 1 is made up of technologies that fit within existing institutional capabilities and current missions ubiquitous learning is currently part of institutional missions and leverages off existing infrastucture in the form of mobile technology therefore ubiquitous learning logically fits in quadrant 1 on the other hand the influence of social technology in knowledge sharing and educational networking plays a role in collaborative learning whilst social technology is within existing institutional technology capabilities it is geared towards new markets and therefore resides in quadrant 2 technologies that provide opportunities for lifelong learning particularly in the form of moocs are a recent frontier for higher education institutions however moocs address the existing mission of continuous learning and as a result fit in quadrant 3 finally quadrant 4 is made up new technologies that address new missions this is the realm of personalised and authentic learning technologies such as adaptive learning artificial intelligence and gamification fit in this quadrant this conceptual model gives a clearer guide on the prioritisation of technologies against the nature of missions markets andor contexts that an institution seeks to address using this model an institution can choose a relevant strategic path to take in addressing its approach to the abundance of learning technologies currently available the model also allows a multiquadrant approach whereby a single institution can have substrategic objectives that fit in more than one quadrant at the same time for an example an institution might be entrenching more offcampus learning whilst at the same improving personalization of learning conclusion highlighting five major learning technologies together with two opportunities in the current higher education environment this paper highlights the forces that are driving the industry technology will continue to be a key driver in the advancement of education well into the future moreover the current technologies are constantly improving and giving rise to new applications higher education institutions remain with the challenge of carefully selecting and adopting suitable technologies in their contexts this paper proposed a model to assist in this task the four quadrants contextualise the institutions current and desired missionmarket states the superimposed core learning characteristics assist institution in finding a practical roadmap for making the most meaningful technology choices the model is adaptable as technologies evolve and new ones are introduced

as learning technologies advance and become more ubiquitous particularly in elearning new opportunities are emerging for higher education institutions to address significant academic and administrative challenges driven by increasing competition changing environments and other market forces institutions are considering learning technologies in order to thrive and remain relevant this study gathered insights from existing literature to propose a conceptual model that supports decision making in the adoption of learning technologies by higher education institutions the conceptual model adopts the transformative framework for learning innovation as its foundation and superimposes the emerging learning technologies model the resulting model provides a clear guidance for higher education institution to achieve five key learning characteristics this paper found that combining these two approaches provides a logical approach for higher education institutions to address organisational strategic and learningspecific dimensions in a coherent format furthermore academics and practitioners can benefit from valuable insights in the proposed alternative approach to learning technology adoption

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introduction guidelines for the ethical conduct of biomedical research ethics increasingly emphasize community engagement as a core ethical requirement in international collaborative research this requirement is supported by a wider literature that highlights the potential roles of community engagement in strengthening the protection respect and empowerment of participant communities as well as enhancing the relevance and quality of research as a consequence of its importance in international guidelines and in the bioethics literature the concept of community and practice of community engagement are also increasingly the subject of academic debate and critique there are for example wellrecognized debates around the specific normative roles that communities can play in strengthening the ethics of research the special edition that this article is contributing to has arisen from a satellite meeting of the world congress in bioethics in 2010 specifically geared towards exploring this normative role in this article we argue that the concept of community plays an important normative role in biomedical research because of the existence of morally significant interplay between the concept of community and that of the individual itself a foundational concept for internationally recognized bioethical values such as those associated with informed consent drawing on our experience of working in community engagement in an international collaborative health research setting in rural kenya we discuss and illustrate two morally significant features of the relationship between individual and community and identify some of the normative work potentially done by the concept of community broadly speaking the first of the two ways in which we explore the interplay between individuals and communities as normatively relevant in this article arises out of the ways in which individuality itself is generated through wider interactions within a surrounding culture in this case the ability of individuals to make free informed decisions about participation in research a key ethical requirement must always relate to the wider understandings attitudes beliefs and practices of the communities to which that individual belongs the community in this instance is the group of people who surround and influence the everyday lives of individual research participants although such a community is likely to be heterogeneous and changing a notion of indivisibility between individual and community suggests both substantive and procedural roles for the latter in normative decision making in health research challenges to a preeminent value for individual autonomy in research have been widely made particularly from communitarian often nonwestern perspectives and in public health ethics we draw on similar thinking to emphasize that generating a context in which consent to research participation can reasonably be considered free and informed will often require engagement with communities as well as individuals and that this will be based on both understanding and trust the second kind of normatively relevant interplay between the concept of the individual and of the community which we explore here arises out of a recognition that in participating in research individuals are drawn from wider communities such that risks harms and benefits may potentially be generated that have traction beyond the individual therefore an assessment of benefits and costs to individuals focuses too narrowly to capture the wider ramifications of research social science research and engagement within a wider community may become an essential process to understand the benefits and risks of individual participation for communities as well as for individuals in this instance the definition of a relevant community would depend on specific features of the research and the context in which it was being conducted this relationship between individual and community is the basis of one argument for the ethical importance of community review or consultation in research further researchers obligations to assess these implications of participation are articulated as professional codes for research and medical ethics particularly where research and treatment occur together in this article we first explore the concept of community itself aiming to illustrate that this is not fixed but contingent on goals and context and that the process of defining a community is itself normative and therefore not ethically neutral the following sections explore the two main themes outlined above for considering community and individual as either indivisible or overlapping supporting individual free and informed decisions about participation and assessing community and individual benefits and risks of participation in research at the same time we discuss the way in which these conditions help to balance the limitations of each the discussion in this article draws upon practical experience based on two published case studies and on our ongoing participation in efforts to strengthen community engagement for a diverse range of studies conducted at an international collaborative research programme in kenya while acknowledging that alternative and additional analyses of the normative role of community are possible based on our analysis the final section of this article addresses important practical issues for community engagement including the importance of trust in informed consent the broad approaches to community engagement that may be needed to address diverse theoretical goals and that new ethical dilemmas may be generated highlighting the role of social relations and processes of learning in engagement activities concepts of community as suggested by the preceding paragraphs the term community is recognized as an amorphous fluid culturally constructed identity that groups individuals together in its most straightforward definition community refers to a sense of belonging together it may refer to a group of people living in the same locality religion race profession or with other common characteristics social scientists geneticists and communitybased box a community perceptions in a genomic epidemiological study in late 2007 a genomic epidemiological study in a rural area of kenya began recruiting 12000 healthy children under the age of 12 months across a district with a population of around 250000 people aiming to assess the relationship between inheritance and susceptibility to many of the commonest causes of childhood mortality through links to hospital inpatient surveillance data predictive testing for a serious and relatively common inherited condition sickle cell disorder was included in this study with the provision of counselling and long term management at the local government hospital for children found to be affected local government administrative leaders and community representatives were consulted initially and leaders worked with research staff to conduct public meetings and small group discussions with village elders and religious leaders across the community to explain and respond to questions about the study community engagement and informed consent processes included informationgiving on scd since the disorder was not well recognized in the community a team of eight field workers local residents with at least 12 years schooling working full time for the research programme visited and continue to visit homes included within a research demographic surveillance system to seek consent for participation of children after reporting of a new birth participation involves the collection of a 02 ml capillary blood sample from the heel along with data on risk factors field workers reported that most prospective participants found testing for scd both more interesting and easier to understand than the genomics study during a subsequent household survey many were unable to recall the main research aims in its early stages the study attracted concerns primarily over safety of the mode of blood sampling and associated issues of trust in the research institution over time field workers report that concerns have diminished with some parents claiming no need for further study information during recruitment where other children have previously participated from the same household box b community perceptions in a malaria vaccine trial in 2006 a malaria vaccine study in a small group of villages within kilifi district invited participation from 400 families with young children including intervention and control groups for eligible children whose parents were consented procedures included a photograph for identification on visits vaccine administration in three injections over three visits to the local dispensary checkups after each vaccination and home visits and blood tests to check for malaria over a year in order to ensure that all health related events in study children were documented parents were encouraged to contact field staff based in the study villages in the case of any illness in study participants the fw could then communicate with the pi by mobile phone in the case of an emergency or directly with the dispensary to ensure the child received treatment this was free of charge for the one year study period the mvt used a multistep informed consent process including discussions with local administration and dispensary committees largescale community sensitization meetings household visits and group discussions at the health facility where the study was being discussed over time tensions reportedly developed between participant and non participant families in these villages in part over access to study benefits participant families expressed strong feelings that rumours about safety and misplaced trust were being fuelled and spread by non participants when consulted about the mechanisms for feedback of findings at the end of this trial study participants refused to agree to information being given to non participants participatory researchers have identified a number of structural characteristics associated with communities that strengthen the normative role of the concept these include relative stability social interactions and established community institutions such that there is sufficient social interaction structure and permanence to allow an individual to identify themselves as a member of a community only occasionally have researchers explored community members own definitions of community clearly there are challenges in drawing boundaries around communities made more complex by considering the perspective of the boundarydrawer as well as the heterogeneity most recognized communities encompass captured by the concept of nested communities membership within a community can be by choice or based on innate personal characteristics such as age geography shared interests values and experiences ultimately definitions of community are likely to be linked to the reasons that groups of people are being termed as communities either internally or externally internal definitions may arise for reasons of empowerment including as part of communitybased participatory research in much international collaborative research definitions are more commonly made externally in relation to the goals and the context of a study including community structure where ways of interacting with a community or community engagement are linked to researchers definitions of community the types of questions typically asked are what are we trying to achieve through community engagement in this situation and why and given this which communities should be involved and how common externally drawn boundaries include kinship for genome research people with a certain disease or riskfactor geographical locality those served by a particular health facility or groups with a commonly identified or legitimately elected leadership research institutions can also be said to create communities of participants an example of a community of research participants was given by the malaria vaccine trial presented in box b and will be discussed in more detail later showing the way that the act of participating in research established mechanisms for information sharing and created bonds between members while excluding others in the wider village community given all of this fluidity the drawing of boundaries around communities will often itself be a normative process with its own ethical implications key among these issues are considerations of whose perspectives may be privileged when boundaries are drawn and with what effect communities in kilifi the kemriwellcome trust research programme kenya the experiences drawn on in this article have been generated through the authors involvement in health research at the kemri wellcome trust programme an international multidisciplinary biomedical research programme started in 1989 as a collaboration between the kenya medical research institute and the wellcome trust uk vm dk and sm have worked in this setting for over 15 years with an important focus on research and implementation policy and practice around community engagement since 2001 the research centre is situated in the district general hospital of this relatively poor rural district the community referred to comprises the geographic population of approximately 250000 local residents who access health services at kdh primarily subsistence farmers belonging to the mijikenda ethnic group with 20 migration from other parts of kenya local tourism petty trading and employment in nearby larger towns provide cash income local administration is the responsibility of chiefs working through assistant chiefs and village elders chiefs are civil servants with at least 12 years of schooling drawn from the ethnic community they serve they are seen by community members as essential gatekeepers for community activities but not necessarily as their representatives the centre works in close collaboration with kdh and ensures that a consistently high standard of treatment is available to all inpatients in many departments including the childrens general and intensive care wards regardless of their participation in research the research centre and the local community have been described elsewhere in more detail community engagement at the kilifi centre is supported by a centralized group of full time community facilitators and draws on action research principles of continuous evaluation and adaptation a summary of community engagement activities is presented in table 1 in common with other a therapeutic misconception of research defined as a belief that what is being proposed is for the benefit of the individual person and has a reasonable chance of success contributes to the mix of community perceptions around research in kilifi this phenomenon has been widely reported elsewhere for research settings in both more and less developed countries prospective participants making a free competent informed choice about joining the study without undue incentives or coercion we also argue that these steps can only support valid informed consent processes when underpinned by relationships based on appropriate levels of trust further and specific to the main argument in this paper that building both understanding and trust must recognize the influence of community on individuals or their indivisibility concept of there is an important debate in bioethics that challenges the concept of individual autonomy as one of the universally predominant principles given the role of communal rather than individual decision making in some cultures in a similar vein it is our experience that individuals considering taking part in research are strongly influenced by the prevailing beliefs and attitudes of the communities in which they live in describing the way that individual ethicalmoral development takes place from a psychology perspective mkhize describes that self understanding emerges against the background social practices provided by the culture at large in a less fundamental way peoples beliefs and attitudes are shaped at any given time by those of others considered significant particularly where there are important paradigmatic differences between researchers and participants in relation to the nature goals and activities in research it may be very difficult arguably impossible to bridge these through interactions with individual prospective participants failure to address these gaps leads not only to challenges in participants understanding of proposed research but to concerns and rumours that may undermine trust in research as an institution and in the people who represent it this conclusion underpins one normative role for community in research ethics building a foundation of wider understanding and trust that allows individual informed consent to become a valid process we recognize that in relation to individual informed consent there are potential risks in building a foundation of wider trust including contributing to an environment in which research institutions and individuals are not questioned and challenged and in which decisions about research participation are based on an unreflective belief that individual and community needs will be prioritized in any research endeavour conversely mistrust where based on misinformation and rumour can lead to automatic rejection of studies with negative implications for both researchers and for community members in the normative role for community in research ethics there is therefore a need to build appropriate levels of trust exhibiting aspects of behaviour and attitudes known to be important in trusting relationships such as openness truthtelling and respect should support a healthy questioning of research staff and institutions among communities and a reasoned assessment of the information discussed as part of researchrelated decisionmaking a genomic epidemiological study in kilifi described in box a provides an illustration of the way that beliefs and attitudes prevalent within a community including trust are linked to individual informed consent processes with potential effects of both supporting and discouraging participation the genomics study aims to generate greater understanding of inherited factors influencing resistance and susceptibility to serious causes of childhood disease in this and other similar areas a qualitative study exploring social and ethical issues around genomics research was also conducted including individual and small group interviews with the group of eight male field workers responsible for informed consent and sample and data collection and 22 families participating in the research during these discussions the relationship between community and individual perceptions of the study was central to the way that the informed consent process was described including acting as a source or as a means of checking information because most of the time in these barazas women are in large numbers in every location you see this there and when they get that information they share it with their friends back home that is how they get to know the information and really because sometimes they do not ask those questions in the meetings but when they are back home they try to see some community figureheads in that community whether its the chief or somebody who is very much elite and try to ask them questions and when they get that information its happily stuck in their heads because maybe where they get the information they get it from a wrong person so they dont really get it clear and know what it really is about or so you will visit the homestead you end up getting a refusal just because somebody has misinformed this person you followed so you go there you try to explain somebody will just say no no because something else is planted inside i asked where he was going to next to a neighbours home so that i could go and ask if he did the same there as he did here i asked the name of the next child to be followed and he told me it was a neighbour i know so i went later to ask and found out that her child had also had blood taken from the heel so i knew that many children will be done the same a form of encouragement to participation arose through a phenomenon close to a therapeutic misconception of research therapeutic misconceptions have been particularly described as an important influence in communities where biomedical research is an unfamiliar activity different models for health and illness between researchers and research participants are common and many people have had little exposure to formal education as these conditions and the quotes above illustrate therapeutic misconceptions can therefore often occur across communities and not just at the level of individuals within that community in the genomics study this misconception emerged in the form of a health check rather than treatment additionally the phenomenon might be more accurately represented here as a form of crowding out than misconception more interesting and easily understood information about scd seems to have been prioritized over more arcane issues around genomics research both by individuals and the wider community all the genomics field workers talked about this bias saying for example that youll just find most of the questions are being asked in the sickle cell part when you are reading that sickle cell part but at the end of the consent youll then ask questions to see if they have understood the whole thing and youll find most of the questions or the answers are just from the sickle cell part even if you go deep and talk about the genetic study still at the end of the day go back to that participant he or she will tell you about sickle cell greater interest in sickle cell testing than the genomics research was also described in relation to the value placed on immediate as opposed to long term benefits there are some who are going to agree because there are those who know what research is all about and there are those who join research because of sickle cell so there are two groups of people those who know about the research and those who join research activities just because of the immediate benefits conversely discouragement from participation often resulted from rumours described as prevalent within the community which could change over time and when you give the consent is kind of afraid of signing its like the rumors around are like to sign the document is like now you have offered the kid to them so its all up to you so she is comfortable with consenting and pricking and everything but putting a signature it took me a lot of time to explain to the mother because she had already understood some fake stories about a kid being pricked by kemri people and then the kid becomes sick yea people were they were afraid of the prick where that prick is being done most of these people these communities they were not used to the heel prick but i think they have come to realize that the heel prick is not that different from the finger prick so that question is not being asked any more the community has come to understand more about the prick than before sighing there have been some places whereby in the neighbouring homestead we were told that when you pricked the child the next day the child became sick but you find that there are some parents in fact that come in and tell the others that even if this child had not been recruited maybe this illness was already coming while health check misconceptions or biases could be seen as important ways in which informed consent is undermined towards undue influence to participate community rumours about research can equally present undue influence on individuals away from participation this false discouragement can be argued as an important loss of a right to participation particularly where research offers an opportunity to test for a serious disorder affecting 1 of young children in the area we could consider this dilemma compounded by the decision on participation being taken by a parent on behalf of a minor however while community perceptions have a strong influence on individual informed choices about research participation there are well recognized challenges to arguments that relying on informed choice alone would support ethical outcomes first there may be a limit to the amount of information shared with potential participants to support such a choice particularly for research which is highly technical while working towards ensuring that all the information required by guidelines is included researchers and reviewers may also privilege components they believe are most important to take into account before making a decision about participation in practice this is influenced by awareness that attempts to convey all the details of planned research during an informed consent process can interfere with participants understanding of the most important implications of participation the decision on what information to present to whom and how while aiming to act as the basis for a participants free choice is therefore one generally taken by researchers and review committees the same pertains to information shared with communities or their representatives as part of a community engagement process second even where complete individual understanding could be achieved there may be conflicts between a participants informed choice and the researchers perceptions of that persons best interests in a clinical trial for example researchers are required to exclude an established participant from a study if they develop a new condition that increases the risks of their participation where participation in a trial secures provision of free medical care for the duration of the study and this would otherwise be less freely available the researchers duty of care may conflict with a participants choice to accept a small or theoretical increase in risk these professional obligations towards research participants generate a requirement for researchers to consider the real impacts that participation may have on a persons health and wellbeing as well their informed choices on involvement in this example the researcher could frame the participants choice as having been unduly influenced by a study benefit of access to medical services thus while concept 1 highlights one fundamental role of community autonomy has well recognized and important limitations in supporting ethical practice when considered alone concept 2 of community describes a second and complementary role for community that contributes to addressing this limitation concept of community 2 assessing benefits and risks to communities of individual participation an important second way in which the relationship between individuals and communities can have normative significance arises out of the fact that the involvement of individuals in health research can have wider consequences for communities this relationship is particularly recognized in genetic or genomics research where links between individuals and their wider families or related communities are inherent to the subject of study and for non genetic research that may generate community risks by association for example stigmatization of linked groups in studies including individuals at high risk for hivaids these concerns contribute to arguments for considering community consultation and even sometimes consent as a critical step in planning and implementing some types of research including supporting decision making about types and levels of information that should be given to individuals and communities in practice community consultation and social science research in kilifi indicate that a less debated consequence of individual participation can be the generation of intracommunity tensions between participants and non participants in research directly linked to the nature of individual costs and benefits a malaria vaccine trial conducted in kilifi described in box b provides an illustration of the potential risk of generating intracommunity tensions as a result of individual participation in research as well as the way that communitywide benefits can act to minimize this effect in this research the provision of medical care for study children was an indirect benefit of participation and highly valued parents of participant children repeatedly highlighted these benefits over any altruistic interest in contributing to the global pool of knowledge on malaria prevention as the main reason for joining the trial what attracted us was that we knew our children will receive treatment for a whole year in every disease they suffer if you have a problem and visit the people concerned a call is made to the pi he brings a vehicle and the sick person is carried away to hospital in fact its something we should be happy about because nobody can bring you a vehicle that easily a potential concern in such a context is for such improved access to medical care in research to act as a form of undue inducement in contrast in this trial better access to medical services generated unforeseen complications of intracommunity tensions participants in fgds described nonparticipants as jealous of the benefits that they were receiving and that these nonparticipants were fuelling rumours about the trial in order to encourage participants to drop out it is said by non participants that we joined kemri and photographs were taken blood was removed and both will be taken there to kemri later they will cut the photo up and the child will start fitting p3 yes the child will fit ie have a seizure laughter and die so kemri are devil worshippers they nonparticipants are out to worry us its a conflict between those who attended and those who didnt so its upon us to educate them so that they dont convince the ones participating to withdraw when they see us boarding the free vehicles they shout a lazy person takes advantage of any chance the circulation of these rumours and concerns were potentially detrimental to wider community cohesion and the completion of the trial regarding the latter many parents described struggling to ignore the nonsense being circulated the vaccine for malaria is still new in our place thats why they are doing it the trial using our children and a lot of nonsense has been going round we are fighting to cross over to truly believing that all of the rumours are nonsense but after the trial you should think about us because we are in the middle of water ie the ones taking the risks we dont know whether well drown or what we are in the middle of the sea the pressures and worries that participants felt they had to cope with in large measure fuelled by nonparticipants reported rumourmongering influenced participants views on what should happen at the end of the study regarding results many participants were keen that there be separate information giving for those who were in the trial and those who were not and in several groups it was strongly felt that nonparticipants should not be given any direct feedback one person even mentioned that nonparticipants should be given the feedback that makes them feel bad some felt that nonparticipants should not be able to access any benefits at the end of the trial the rabies vaccine control vaccine should be given to those who participated only but not to those that refused to participate even if a dog bites one they shouldnt tell them there is the vaccine at the dispensary they should go to kilifi kilifi district hospital because this vaccine is for those that participated in the study discussions with nonparticipants on the other hand revealed concerns about not being involved in the study once it was underway they noted that they did not have much information on the status of the study or any information on what the participants received and that they had to wait and ask their friends and relatives who had children in the study others stated that they were not interested in what had gone on i wont ask you in fact i will refuse to know what you have i dont want you to tell me what you have been told there eeh overall a dispensary committee members comment may have given a good general indication of how many nonparticipants felt it is like the community members were starting to group themselves and were taking themselves to be that the study people are the important ones and those not in the project should not benefit again because they refused it at the beginning it is unclear how serious the intracommunity tensions really were and for how long after the completion of the trial they continued nevertheless in this situation increasing access to medical services for the wider community through collaboration with government health providers is a potentially important strategy to reduce the risks of both intracommunity conflict as well as undue inducement for individual participants as a longstanding research institution this partnership with government medical providers has been possible in kilifi and routinely supports provision of medical services to many research communities particularly where longitudinal cohorts are recruited although the intracommunity tensions involved in this case study might be considered unique to this particular type of study or context we have noted similar issues in mixed methodology social science studies conducted in both kenya and south africa where the importance of providing communitylevel benefits was also highlighted in so doing it was recognized that new potential concerns arise including defining who the relevant communities are what the appropriate levels and types of benefits are who should provide those benefits and how individual interest in joining studies is maintained through compensating participants for the time and inconvenience involved we have illustrated a negative consequence for communities arising out of individuals participation in studies with potentially positive implications in terms of strengthening the focus on community wide benefits to avoid such problems there may also be more direct positive communitylevel consequences arising out of individuals participation in studies which are more typically recognized by researchers for example an individual participating in an hiv trial which involves significant informationgiving about the disease and available support groups may contribute to participants sharing that information with other community members and to improved health and strengthened social networks another example is that indepth interviews about health financing policies may lead to greater discussion awareness and possibly even advocacy among wider communities for change in policy or practice it follows that researchers have a responsibility both to support participants free informed decisions about involvement in research and also to assess the ethical implications of these decisions taking into account other issues such as risks and benefits both to the individual participant and to the community of which they are a representative further engagement with a wider community will often be an important process to support informed consent and understand community benefits and risks in practice in the next section we address this procedural role of community highlighting the breadth of approaches used in kilifi to support individual choice and assess community risks and benefits in research we also point to challenges in this process that can in our experience lead to perverse outcomes primarily related to communication and the fundamentally social nature of many engagement activities working with concepts community engagement goals and activities in kilifi we described earlier that researchers will often identity communities that can support individual free informed choice or assessments of the benefits and risks around participation in research in relation to the type of research and the wider context for a study including the particular groups of people who may become involved in its implementation as an illustration of the breadth of approaches that this may involve table 1 outlines the types of goals that have commonly been defined for research in kilifi the communities involved and the range of activities currently put in place to work towards these goals given the central role of trust in this engagement process it has been particularly important to build understanding of the research programme as an institution ensure transparency and accountability in its policies and build coordinated supportive policies on staff training and monitoring as well as community engagement itself the community engagement activities described have been developed over a period of time linked to the findings of linked action and empirical social science research these experiences and studies have strengthened our understanding of the issues and dilemmas that can interfere with the pathways between planned community engagement activities and their intended ethical goals further that new ethical issues can be generated through these initiatives based on our experience of supporting research teams to develop and implement community engagement plans we offer three examples of such perverse outcomes around dilemmas on who to engage with and dangers of half knowing dilemmas on who to engage with based on a recognition of the importance of building understanding and trust of research among communities as well as individuals and of the potential value of consulting community representatives in early discussions on the potential risks and benefits of research researchers involved in a current vaccine trial included in their pretrial community engagement activities chiefs village elders and community health workers among many others although this was essential and there were many positive consequences of doing it two important dilemmas emerged first it became apparent that one of the chiefsin his capacity as an administratorwas taking it upon himself to organize meetings about the trial and to put significant pressure on parents with eligible children to enroll their children in a famine prone area he had reportedly threatened to remove tickets for free food rations from eligible families who did not enroll for this study these threats were reported with significant laughter by community members and efforts were redoubled by the research team to emphasize the voluntary nature of trial participation nevertheless the incident highlighted that engagement with community members always involves engagement with existing social relations and hierarchies and that this can have perverse consequences in this case potentially for individual informed consent and for intracommunity relations a second dilemma was that on engaging with chws as strongly suggested by ministry of health collaborators it became clear that chws themselves would like to assist with the study in part in order to receive some payment for their work and therefore benefit from the study this was an understandable interest given that few chws following selection and training by moh have been supported to implement their training due to resource shortages a challenge became if and how to involve chws in addition to the existing trial team whether to pay them at what level and the potential implications for informed consent and community relations there was a concern that payment of any form might lead to tensions within communities and others involved directly or indirectly in the study requesting payment on amount to pay there was a concern that if this was based on numbers of people recruited there might be inappropriate levels of pressure on parents of eligible children but on the other hand that a flat payment for example per day may lead to unfairness between chws and between chws and others involved in the trial an appropriate resolution appeared to be payment on the basis of numbers of people chws brought to the study clinic to learn more about the research however these issues highlighted complexities regarding who to consult at what stage and how and that community representatives own needs might feature as much in discussions as those of potential participants and the wider community the dangers of half knowing the effect of low understanding of research and greater familiarity with medical services in generating therapeutic misconceptions has been described as an important ethical rationale for building greater awareness of research including through community engagement we have observed in kilifi that in practice understanding is not only challenging to achieve but that incomplete levels of understanding or half knowing are almost an inevitable accompaniment of communication efforts further there are dilemmas created around half knowing about research that engagement strategies have to respond to for example efforts to explain research and the difference between research and treatment have included messages about the voluntary nature of research participation and the availability of standard care for non participants for example in clinical trials where understanding enables research to be recognized as different to medical care rumours and concerns can arise where alternative more accurate explanations are not available or understandable in this paper we have discussed a range of these rumours and concerns in kilifi and elsewhere linked for example to doubts about researchers motives and the safety of procedures consequences may be community tensions the inability to generate social value through research and loss of rights of participation a further outcome of half knowing can be that recognition of the voluntary nature of research accompanied by challenges in differentiating between specific examples of research and treatment can lead to rejection of treatment in a relatively wellresourced research centre more complex diagnostic procedures are often available than would be the case in typical public health care facilities at kdh we have experienced that diagnostic procedures important to the wellbeing of a patient have been refused on an assumption that this is part of research voluntary and nonessential the danger of half knowing here is the potentially negative consequences for clinical care or more likely and more subtly of unnecessarily raised concerns about standard clinical care procedures ultimately there is a potential risk of patients avoiding key public health facilities in which research is happening in order to avoid research altogether community engagement strategies that continue to build not only understanding of research but also mutual trust have an important role in addressing these perverse outcomes however again we acknowledge that an increased but still incomplete level of knowing could contribute to the inappropriately high and unreflective levels of trust referred to earlier in this article we continue to resolve these issues through for example refining messages and through communication skills support to health workers and study teams however the dilemma is that while community engagement has the potential to strengthen individual informed consent and to reduce the likelihood of therapeutic misconceptions or crowding out of key researchrelated information the concept of research and of different studies remains difficult to get across half knowing will almost inevitably be an outcome and the implications of this at individual and community level need to be continuously taken into account conclusions in considering the normative role of communities in international collaborative research we highlight the contingent nature of a community such that applying definitions is itself a normative process with ethical implications often related to the perspectives of the boundarydrawer drawing on experience of working with local residents in a rural setting in kenya we identify two normative roles played by communities in this setting first that taking individual informed consent seriously involves understanding and addressing the influence of communities in which individuals lives are embedded second that individual participation can generate risks and benefits for communities as part of the wider implications of research and that these should also be taken into account community engagement is an important process to address these issues but may require a broad approach to build mutual understanding and trust between researchers and community members we emphasize the challenging nature of these communication efforts including the need to continually work towards understanding and addressing the risks of perverse outcomes using examples related to the influence of existing social relations and the inevitable complications of half knowing we are grateful to local residents and community leaders in kilifi district kenya who have participated in the community engagement social science and action research studies on which this article draws field workers in the genomic epidemiological study malaria vaccine trial and the social and behavioural research group have made invaluable contributions through participation or supporting collection and interpretation of data we have also relied on the inputs of salim mwalukore community liaison manager and his team of community facilitators and patricia njuguna malaria vaccine trial coordinator at the kemri wellcome trust research programme and caroline gikonyo social scientist thomas williams is the principle investigator on the genomics study and philip bejon was the principal investigator for the malaria vaccine trial and we thank them for supporting the research around their studies reported on here and for their review of this article this article is published with the permission of the director kemri acknowledgements

the importance of communities in strengthening the ethics of international collaborative research is increasingly highlighted but there has been much debate about the meaning of the term community and its specific normative contribution we argue that community is a contingent concept that plays an important normative role in research through the existence of morally significant interplay between notions of community and individuality we draw on experience of community engagement in rural kenya to illustrate two aspects of this interplay i that taking individual informed consent seriously involves understanding and addressing the influence of communities in which individuals lives are embedded ii that individual participation can generate risks and benefits for communities as part of the wider implications of research we further argue that the contingent nature of a community means that defining boundaries is generally a normative process itself with ethical implications community engagement supports the enactment of normative roles building mutual understanding and trust between researchers and community members have been important goals in kilifi requiring a broad range of approaches ethical dilemmas are continuously generated as part of these engagement activities including the risks of perverse outcomes related to existing social relations in communities and conditions of half knowing intrinsic to processes of developing new understandings

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india in the 1980s agantuks opening sequence depicts the arrival of the protagonist of the film manomohan mitra a lost uncle returning to kolkata on a train after thirtyfive years of absence he is an experienced cleanshaved gentleman who confidently places his feet on the wagon seat he is wearing polished shoes but has no etiquette manners at home nobody remembers or recognizes him and he is treated suspiciously even by his own family following the constant interrogation by his niece anila and her suspicious husband sudhindra the uncle explains his long absence by portraying his outcast condition as that of an anthropologist he claimed he disappeared for four decades because he wanted to satisfy his curiosity about the world first in terms of understanding what is primitive and civilized and second to satisfy his wanderlust the urge to travel to learn and to question he is the caricature of the lost anthropologist a modern odysseus returning to his longforgotten and unrecognizable ithaca this caricature of the stranger never confirmed or renounced remains an ambiguous liminoid persona a traveller who is paradoxically trapped or confined in firths terms inbetween two worlds the home and the world only in the end of the film he finally rests in the back garden the only space that has survived the rapid changes that took place during his absence just like a buddha the stranger finally finds rest under the tree of knowledge and wisdom this anthropological calling in many ways also refers to the auteur himself the four decades of the uncles absence echo the four decades of the directors work for those familiar with rays films the opening sequence of agantuk feels as if the boytrickster apu from his worldfamous debut pather panchali grew up into an anthropologist this essay throws a new light on the films of satyajit ray approaching him as an auteur whose work not only critically reflected upon the history and society of his time but recontextualized india within our globalized world society it pays a tribute to rays filmmaking by critically examining modernity as an impersonal alienating fastmoving process of rapid change it examines particular aspects of modernity in relation to rays films urbanization disenchantment private alienation and social alienation through his symbolic use of objects of modernity the train the binoculars the book the mirror the forbidden love prem tourism imported cigarettes and mercedes cars among other objects of science and desire in this way the essay will be reflecting on the historical predicament of anthropology as a colonial byproduct of european modernity set against rays caricature of the anthropologist in agantuk the lost longforgotten uncle returning to a home that does not belong to him anymore apus eyepather panchali one of the key sequences in rays debut pather panchali is the train sequence ray juxtaposes two settings the povertystricken and collapsing home of apu in the dark forest against the brightly lit sequence with the train crossing the open countryside the sequence begins with the sound of a walking stick off the screen that painfully announces the arrival of auntie indir at apus house anyone at home she asks apus mother sarbojaya ray offscreen bitterly replies why have you come back following their argument over indirs bad influence on her daughter durga according to malicious gossip the mother remains cold separately eating some nuts in a dark corner of their house while keeping her eyes away from indir with her warm smile the old indir says i am not feeling very well id like to spend my last days in the old home sarbojaya nervously replies what is the old home to you the best thing you can do is leave apus sister durga watches as she bites off pieces of bamboo apu approaches behind her and they both run playfully outside the forest into the fields apus image wearing his golden crown made out of paper cuts echoes classical depictions of the young shiva as if he is playing with his sister saraswati the goddess of knowledge and music who is related to the mother goddess durga cut back to the dark foreground of the house where sarbojaya remains cold but worried at the same time of an insecure future ray juxtaposes the dark foreground of the wrecked house to the brightly lit background of the garden that covers the old indir the silence of the dialogue between the two women accompanied by the tensed repeated and dissonant background note of ravi shankars sitar that gradually comes to the foreground of sound amplifies the ambience of alienation and isolation ray contextualizes these feelings within the home that has become unbearable because of poverty indir waters a small tree picks up her bangle and stick and walks out of the garden sarbojaya stares at the empty space bitter angry and hurt in the dark foreground of the wrecked house a dog is searching for food amongst the junk in yet another dialectic juxtaposition ray contrasts the shadow image of the dog a symbolic image of decay and death to indirs last stare at the house as she walks off screen to meet her death in the brightly lit forest the second part of the sequence continues on the double setting motif with a cut to a longshot that portrays apu standing in the windy fields of hey at the background of the frame juxtaposed to the parallel and static image of the electric wires that cut the frame diagonally in two apu is staring with wonderment at the electric bulbs at the top of the pillar standing against the moving clouds in the next cut his sister durga first looks at the wires and then at apu in a suspicious way durga tries to identify the foreign sound of the electric wires from the splashing sound the two kids are making as they walk through the muddy field ray musically orchestrated the scene by following the monotonous disharmonious electronic sound of the soundtracks synthesizer which amplifies the feeling of insecurity about something foreign and alien arriving at long distance this echoes durgas uneasiness with the setting in contrast to apus wonderment who places his ear on the electric column trying to hear the electric sound of the column the two kids continue wondering around in the fields and when apu loses his sister from sight she smoothly throws at him a small stone so that he can find her durga like a mother to him shares her bamboo stick as they both sit in the shadow of long grown hey blowing in the vivid wind where are we what are those apu curiously asks pointing his finger towards the electric wires durga moves her head indifferently but then covers apus mouth as she hears again the foreign sound of something approaching from a long distance a mechanic repetitive sound coming along with the natural sound of the wind they both stand up to see where it comes from gradually the wind gives away to the monstrous sound of a train while durga falls on her knees in fear at the sight of the train approaching the excited apu runs towards it almost as if he wants to touch it he runs along the railway behind the black figure of the train that rapidly passes in front of the camera apu looks in wonderment at the black smoke the machine has left behind auntie indirs death follows the ground breaking pather panchali introduced the world audiences to rays unique authority and observant camera the apus eye referring to a particular way of positioning the camera from the point of view of a child cooper exclaimed that the use of the apus eye illustrates the aesthetic value of the epiphany of wonderment according to the classical hindu aesthetical form of rasa these moods refer to the emotional comprehension of the directly experienced inward life that all art conveys as a guiding principle behind the creation in agantuk ray gives apus eye point of view to satyaki the strangers nephew who shares with his lost uncle a paradoxical alienation from as the means of engaging with the world this selfalienating condition is affine to the alienation of the ethnographer in the field the observant apus eye distant and detached amoral and creative at the same time distanciated in order to function as a higher ethical force that allows the viewer to enter this world from an insiders perspective it is an amateur neoromantic innocent eye of a visionary fieldworker the observant seer filled with childlike curiosity and playful amorality the curiosity of the child is illustrated in pather panchalis train sequence above in which apus curious eyes are wide open in wonderment embracing the marvels of this fastmoving machine whose metallic sounds rip the peaceful countryside apart his curiosity is accompanied by an innocent emotional detachment as illustrated in the end of the film by his playful realization of his sister death apus detached perspective exposes the hypocrisy of village life by juxtaposing dreamy scenes from the life of the two children in the forest enchanted with the amazing music score of ravi shankar against cruel dialogue in scenes portraying everyday life gossip corruption cruelty accusation jealousy social suffocation isolation and desperation in this dialectical way ray highlighted issues of poverty lack of education and religious superstition in front of this misery human relationships particularly between durga and indira and apu and his mother feel like oasis in a world of suffering from which however apus innocent perspective remains detached in this suffocating world the appearance of the train in apus life is also the means to escape from it in the two films that followed pather panchali aparajito and apur sansar ray portrays the personal transformation of the boy to a man along with the historical transition from an agricultural feudal state to the new democratic india as ganguly pointed the trilogy generally reflects positively on nehrus modernization project which began following the indian independence in 1947 rays emphasis on english science and geography is a vindication of the values of bengali renaissance which are also the values of nehrus modern india the latter was characterized by an ethos of citizenly solidarity with the poor middleclass indians were cast as the agents and overseers of industrialization and developmental schemes for rural communities and also as the guardians of the normative morality that preserved the social fabric of the modernizing nation ray illustrates this collective optimism in the final scene of the third film apur sansar in which the middleaged bearded apu holds his son on his shoulder as they both stare at the future in the bright sunlight the train the most recognizable object of modernity associated with urbanization and rapid industrialization is used throughout rays filmmaking as a carrier of internal and external changes both on a personal level for his characters and the bengali society respectively the appearance of the train anticipates apus move from the countryside to the big city along with his transformation from a curious child to a responsible father throughout the trilogy the train brings changes in the social life of the characters from village life of absolute poverty to the crowded apartments of the new calcutta ray challenges the optimism of pather panchali in the second film of the trilogy aparajito in which the train becomes a symbol of dislocation separation and a vain hope for reunification in this film the train contains a new set of problems in family relationships that rose because of the rapid urbanization of india with the new generation of educated bengalis leaving behind their families and village poverty for a new life in the big city rays disillusion with nehrus modernizing project continues in nayak in which the train becomes the static mechanical setting juxtaposed to a rapidly passing landscape seen from the carriages window as the constructed image of the protagonist film star is gradually exposed until his ultimate alienation is revealed similarly in rays adaptations of tagores short stories the sound of the train offscreen anticipates sudden and often cruel and unpredictable change becoming a source of anxiety finally in agantuk the forgotten uncle returns to kolkata on a train to an unrecognizable and alienated home the train is thus a gift of modernity to the world on the one hand a gift and on the other a poison p 81 this object of modernity connects the home to the world the village to the city different individuals to each other their memories intentions and expectations it is the carrier of the collective hopes and grievances of an entire nation tagore and ray citizens of the world rays unique artistic authority was the result of his cosmopolitan upbringing his family was relatively wealthy with a reputation in the arts and literature going back to fifteen generations his grandfather upendra kishore raychowdhury and his father sukumar ray were illustrators of childrens stories in their magazine sandesh from an early age ray was exposed to indian mythology and its various forms of narration he was well educated in arts and music combined with a degree in economics from the presidency college in calcutta followed by further education and in british and american institutions in his trips inside and outside india ray met various intellectuals including the film director jean renoir son of the famous impressionist painter and jean luc goddard who was a major influence on his political films in the 1970s his debut with apu trilogy acknowledged the influence of european neorealist cinema of jean renoir and vittorio de sica as in italian neorealism ray often used amateur actors long semiimprovised takes a multivocal and multilayered script shot on location and using natural light when possible while also introducing the cinematographer subrata mitras bouncing light the use of white sheets and mirrors to imitate natural light and create the aesthetic of reality the director pointed out in an interview that the realistic depiction of the forest was exclusively imagined in nostalgic ways as a lost bengali past satyajit ray channel 4 uk 251991 despite its manufactured realism pather panchali won the first prize for the best human document in cannes in 1956 instigating rays humanist reputation for being a bengali renaissance man the trilogy consolidated very early in his career the nature of rays humanism living in an emerging marxist intellectual ambience in bengal ray held on to his tagorean beliefs and rejected the methodology of marxism the crux of this social philosophy lies in the importance of the growth of the individual mind and the influence idealism exercises through religion and art to prevent it from extreme selfseeking at the cost of the welfare of others the goodness of the individual in this view is the basis of social growth rays humanism shared the aesthetical values found in rabindranath tagores music paintings prose and poetry as acknowledged in his commissioned documentary produced in 1961 in honour of the poets centennial tagores aesthetic influence on ray is evident in films such as devi furthermore rays frequent adaptations of tagores short stories often focused on the emancipation of women in 19 th century bengal as in teen kanya charulata and ghare baire both tagore and ray wrote about an imagined melting pot a fastchanging multicultural calcutta used as an everyday arena in which heterogeneous cultures communicate with andor contest against each other they were both travellers motivated by the wanderlust the internal urge to travel to question and to learn as expressed in agantuk by the caricature of the lost uncle during his life tagore visited more than thirty countries and met several intellectuals including ezra pound thomas mann george bernard shaw hg wells and roman rolland scientists such as albert einstein the persian mystic hafez and even with the fascist mussolini the experience of travelling for both tagore and ray thus not only engaged them with other peoples ideas and habits but also resulted in keeping a distance from their own bengali culture while still living in calcutta their sense of alienation from home enabled them to observe and record the impact of the social economic and political changes brought by the train of modernity on the personal lives of their fictional characters and to critically reflect upon the historical and sociological issues of their respective times arguably tagore and ray felt strangers at home both confined inbetween british colonialism and indian nationalism an imprisoned condition of bengali identity which tagore elegantly expressed in his widely appraised essay on nationalism in india as sen put it the tragedy as tagore saw it came from the fact that what was truly best in their british own civilization the upholding of dignity in human relationships has no place in the british administration of this country in this context rays last film agantuk is a selfconfessional testament of the directors marginality inbetween the artistic tradition of his brahma family and bengali renaissance and his european education and bourgeois upbringing seen either as contradictory or as complementary to his indianess nevertheless the rigid dichotomy between tradition and modernity as well as indian and european modernity makes it impossible to take full account of the contestations that animated the creative efforts to fashion a vibrant culture and politics of anticolonial modernity in this sense tagores and rays fusion of indian with european aesthetic values and narratives challenges the misconception of authentic traditional cultures as opposed to hybrid modern cultures while strengthening the ability to contest western colonial power in the arena of politics and the state seen in its totality the work of the poet tagore and the filmdirector ray articulates a kind of selfcritical historical consciousness as the means of actively raising a collective selfawareness between the past and the future between what is done and what can be done in this context the study of history instead of a passive allegedly objective narrator of the past rather becomes a political agent of dynamic change the ethical means to reflect upon the hope for a better future a study of disenchantment devi both ray and tagore were members of the brahmo class founded by raja rammohan roy an eminent intellectual of the 19 th century rejected idolatry and caste the brahmos were interested in social reform and in changing of existing social systems in this context they were both eager to express their distaste for the caste system and its inherited inequalities ray portrayed the disintegration of the zamindar feudal system in jalsaghar and devi while jalsaghar takes a rather pitiful view of the delusional zamindar biswambhar roy whose music room is an imagined remnant of a nostalgic past devi is a much more forceful film based on mukherjees story written in the 1890s the narrative takes place in 1790s but the film is set in 1870 in chandipur rural bengal devi is the story of doyamoyee whose fatherinlaw kalikinkar roy has a vision in which his daughterinlaw presents herself to be the reincarnation of the goddess durga as in the musical sequences of pather panchali ray constructed the openingcredits of devi in the form of a music piece the film begins in low pianissimo gradually building on a carnivalesque crescendo the first closeup depicts an unadorned head statue of the mother goddess ma made of alabaster staring at the camera with enigmatically blank eyes and smile she maybe parvati the reincarnation of sati who was the first wife of shiva and daughter of the himalayas and whose desire lured shiva into the material realm parvati is also known in seven different namesforms including that of durga and kali as the music changes motif following a dissonant suspensenote played by violins against the low sound of ustad ali akbar khans sitar ray superimposes on parvatis face the mask of durga as the music increases its tempo and volume with the introduction of a tabla and violins at the background the tabula rasa of the mask is then transformed into the statue of kali through a second superimposition of jewelry black hair and makeup placed on the head of the white goddess the music then explodes into a festive tone with the ringing bells and tablas heard during durgas and kalis harvest festivals that take place in the autumn in this way ray portrays the mythological transformationsreincarnations of parvati through an evolution of ma the imago dei of the mother goddess on three levels first the enigmatic headstatue and the simplicity of the marble represent the essence of the masculine symbol of the mother as a provider and preserver by textually referring to prehistorical times the second form evolves into the mask of durgakali used in everyday life to be seen in private houses and public performances in temples finally ray completes the evolution of the face of ma in the third image of the ornamented statue of kali used in festivals this second part of the sequence incorporates an ethnographic recording of kalis annual celebration that takes place three weeks after durgas more prestigious celebrations on the dark moonnight of the month of kartik the ritual culminates at dawn with a firework display followed by a ceremonial procession to the riverbank where the disposal of the tabula rasa in the river takes place following the hypnotic sequence of shots with the various faces of ma the introduction of ringing bells and chimes brings back the audience from a trancelike state into the festival ray zoomsout of the face of kali to the full body of the tableau covered in smoking incense then panning further back the camera gradually reveals the participants of the ritual performance then moving out of the temple where children are playing among the gathered crowd at the same time a subtitle introduces kali to the european audience the mother goddess is revered in bengal as ma the mother belief in the human reincarnation has been widespread in india this story is set a century ago cut to a middleshot of the two male protagonists of the film the zamindar devoted father kalikinkar roy next to his son uma both praying towards the heavily decorated statue the fathers eyes look reassured about himself and his faith with a reverseangle shot the camera reveals the eyes of the mother goddess focusing on his eyes as he falls on his knees to perform piously his offerings to her a series of jump cuts follows that take place in the garden of the temple where a sacrifice is performed under the vivid sound of the participants timpani a closeup on the sword of the executioner as it falls on the head of the sacrificial animal rapidly jump cuts to the image of exploding fireworks in the sky in the third part of this epic opening sequence the music changes from the live recording of the ritual to the sound of a european brass band the camera pans from right to left moving into a closeup of the face of the boy koka carried on the shoulder of his uncle uma this is an image reminiscent of the final image of apu sansar in which apu carries his son on his shoulder staring at a bright future however in this film the light is artificial produced by the fireworks and loud explosions that bring anxiety to little koka before they disappear into the silent darkness of the night sky as the camera pans to the left we see for the first time the image of umas young wife doyamoyee or doya she stares at the fireworks with a shy smile in her sad eyes as she turns to look at her husbands eyes the camera pans back to the left to follow koka and uma the next shot dissolves to a second ethnographic recording portraying the morning mass procession of kalis temple to the river where it is thrown at the end of the festivities the camera focuses for a final time on kalis face before she is thrown in the dark water submerging into the abyss of the jungian soul in the next sequence uma announces to doya his departure to calcutta to study leaving her alone with his father kalikinkar at home this now explains the sadness in doyas eyes this ethnographically abstract portrayal of the rite of passage of the persona of the ma a masculine archetypal symbol of motherhood creation and destruction portrays the evolution of the abstract faceless form of the symbol into a ritual mask and then into a social persona becoming alive through ritual it echoes mausss essay on the notion of the person and the notion of the self in which he drew the evolution of the persona from the sacred use of masks in rituals to the legal constitution of the roman person and through the cristian moral person to contemporary psychological ideas of the self in similar terms devi portrays the evolution of the archetypal symbol to the liminal mask and from the mask to the temple where she becomes a living goddess disappearing in the muddy waters of the sacred river in devi the evolution of the mask to a social persona anticipates the rite of passage of doya from a young innocent girl to a living goddess adorned and worshipped by a male crowd the patriarch system of exploitation represented by her fatherinlaw makes her to wear the social mask of ma becoming a living extension of the mask in the story doya is the young wife of the openminded uma who represents the social aspirations of the youth of the time the novel was written umas pride in his english education which he calls new learning as opposed to his fathers old learning based on studies of tantra and shakti the film begins with umas departure to calcutta to study leaving doya alone in the house with her fatherinlaw and her brotherinlaw his wife and their young boy koka in one of the opening scenes that takes place in kokas bedroom in the evening in the absence of his father his auntie doya tells him scary stories in the companion of his mother this intimate scene echoes old indirs stories to the young durga and apu in pather panchali ray abruptly interrupts this moment of family happiness with a cut to doyas fatherinlaws vision that takes place in his bedroom alone in the second part of the sequence the scene shows kalikinkar piously praying but then having a troubled sleep until his sees a vision in his dream just before he wakes up at dawn in his vision kalikinkar first sees the drawing of the three white eyes of the mother goddess appearing from the abyss of the dark background the jungian depths of the human soul the director zoomsinto the drawing giving the impression that the eyes are gradually coming closer to the camera audience roy as her eyes become bigger the third eye of the forehead begins floating giving life to the mask which is then superimposed on a closeup of the face of doya staring intensely at the camera audience roy a shadow covers doyas face giving the impression that she is a living kali then a bright light falls on her face and she is instantly transformed into ma as in a magic trick nevertheless unlike the traditional iconographies of the mother goddess she takes the conventional position given to women at the time shy slightly bowing her covered head in understanding or submission smiling at the camera ray superimposes on her face a floating set of candles which then dissolves onto kalikinkars shocked anxiously sweaty face who stares intensely at the camera a strong white light highlights the face of the archetype of ma contrasted to the black background of kalikinkars vision in this dialectic manner ray visually synthesizes the act of female emancipation from the oppression of the male perspective as a clash of perspectives in this dialectical manner kalikinkars vision idealizes doyas face visualized as a luminous imago dei in jungs terms or in hindu philosophy a mirror of the illusion of the inner self which is only revealed by intuition by revelation when it is understood to be one with the universal spirit by contrast the dark shadow of kalikinkar carries an emotional nature a kind of autonomy and accordingly an obsessive or better possessive quality gradually this luminous image of the sacred ideal of ma dissolves into the sad face of doya the clock sounds five in the morning as the fatherinlaw stands up in selfrealization that doya is the mother goddess according to his vision this second superimposition echoes the second transformation of the mask to the statue of kali in the opening credits as the recorded celebration of kali follows in the opening sequence the third part of this sequence begins with the sound of ringing bells used to wake up both kalikinkar and the viewers out of the trance state of his vision echoing the third part of the opening credits kalikinkars vision is followed by the image of collective veneration this time not of a statue but of doya by a group of male worshippers begging for miracles kalikinkars vision becomes complete his superstition is materialized by imprisoning doya in a temple making her a public spectacle a zoomout reveals her positioning as she is sitting in the centre of the villages temple in daylight being the focus of attention by her devoted and desperate spectators following this vision the possessive zamindar displaces doya in the villages temple as his holy mother who will perform miracles and protect his village from destitute illness and death a series of juxtapositions of gazes further reveals the extent of the collective devotion attributed to her alleged healing protective and forgiving powers a reverse angle then reveals doyas durgas gaze facing this collectively irrational situation from which she is alienated as a result of being the sacred focus of attention her higher position in the frame looking down at those worshipping her illustrates the intimacy of the visual exchange between goddess and worshippers bhatti and pinney defined the exchange of looks in the context of puja as darshan dena and darshan lena in a durkheimian moral sense the zamindar lord and his flock identify good energy as collective and this gives them the excuse they need to use the female body in this fetishizing manner on durkheims moral basis the collective associated with tradition is thought to be morally higher than selfinterested individualism envy and greed which are the sources of nazar lagjani this moral opposition of darshan and nazar echoes durkheims contrast of religion to magic the former defined in terms of common good the latter in terms of selfinterest however although kalikinkars paternal gaze superficially takes the form of darshan this is accompanied by his envy towards the youth of his son in the sense devi offers a dynamic moral reverse of the durkheimian model of the sacred community in this manner ray does not approach religion as the unifying external and a priori sacred force but as an arena of contestation and competition between individual actors this competition takes place through the juxtaposition of gazes which illustrates bhatti and pinneys concept of opticlash giving and taking darshan is understood in terms of modern reciprocity yet another train of exchange as a kind of a gift above however the death of an ill child in her lap exposes doya as a symbol of exploited womanhood rather than a goddess the film then turns nightmarish for doya and the audience it echoes the suffocating images of poverty of pather panchali but this time oppression has a gender and occupation in the end of the film doya tries to escape from the masculine world that imprisoned her disappearing in a field of wheat that leads to a lake at first her act looks as irrational she runs to the fields ignoring her husbands pleas to move to the big city it is an escapist act of denial as well as an act of acceptance above all it is the final act that reveals her agency for the first time in the film doya might submit to her fatherinlaws vision as her body posture betrays at least on the surface and as she is conventionally meant to but she never fully identifies with it and her uncles abusive point of view at any point of the film visually doyas final exit is identical with the closing ceremonies of durgakalis celebrations depicted in the opening sequence of the film her submergence into the abyss of the dark river echoes several myths regarding the mother goddess one of those is in the form of uma shivas gentle wife and the daughter of menaka and himalaya who standing in for the missed daughters of youth evokes real longing another could be the form of the ascending parvati who went to the mountain laid aside her ornaments and put on garments made of the bark of trees in this context kalikinkar vision is a false one it is not a divine revelation but rather a symptom of his own freudian sexual frustrations these are manifested in the antagonism towards his son and the way he gazes at his daughterinlaw accompanied by several sexual innuendos throughout the film these details constantly reveal his selfishness as sexual obsession yet the film is about female shakti within herself woman contains shakti the tension between cohesion and disintegration often translated as energy it is because of the sexual oppression and selfishness of her fatherinlaw that her shakti is repressed and leads her to disappear into the dark water of subconsciousness this kind of willing suicide allows her shakti to find full and total expression in a world that has been repressing it in this dynamic context doyas disappearance is not a passive act of suicide but an intentional break that results to the social marginalization of kalikinkar and to his public exposure for his greed and envy in his much later film about male shakti entitled sadgati which was an adaptation of the hindu novel by premchand for the tv ray further attacked the inequalities inherited within the feudal system sadgati tells the story of yet another hypocrite and selfindulgent priestlandlord who like a blackmailer uses his traditional status to exploit his servant the servants name is dukhi meaning the one who is always in pain and who belongs to the lowest caste strata of sudra this late tv film production was a return to rays early neorealist aesthetic but in the genre of black comedy ray renegotiated the caste system through the concepts of shakti and the inert shakta the lowest state of human existence shakta refers to the blocking of the channels that allow shakti to be expressed to the point of death as in devi similar to kalikinkars selfpiety in devi sadgatis opening sequences portray the property owners rituals that demonstrate his absolute bhakti as well as his high status and authority yet his cruelty and exploitation of dukhi and his family do not remain unpunished ray reverses the concepts of dharma and karma in the context of death as moksha and sadgati while the landlord is expected to transcend to a higher level of existence because of his pure way of life he is ironically left with the dead and polluting corpse of dukhi which he has to deliver and dispose thus wasting his own shakti in sum devi and sadgati offer experiential understandings of how the caste system works focusing on the inequalities it inherits with openending narratives that allow several interpretations of the content further the two films show a society on change with historical and political implications projected directly on the life of the characters they offer a much more realistic and dynamic picture of the caste system emerging through and within world poverty and discrimination this reexamination of poverty sharply contrasts classic anthropology of india as for example louis dumonts famous homo hierarchicus in which he argued that equality and hierarchy are not in fact opposed to each other but they are in a complementary relationship in daily life thus naturalizing the caste system as a way of social stratification in his criticism of dumonts approach to the caste system deliege associated this durkheimian holistic view of indian society as akin to analyzing european society exclusively through the bible which excluded individual agency and historical change through the static lenses of hierarchy and purity devi and sadgati challenge this ideal of a sacred village community based on european stereotypes of purity and pollution as frequently used in anthropology at the time devi was produced by focusing on the historical changes of his time through the life stories of socially oppressed individuals ray exposed the selfinterest and motivations of their feudal lords offering thus modern tales of escapism from the past and disillusion with the future from the inside while remaining an outsider himself rays adaptation of tagores nastanirh in charulata offers another critical perspective on the emancipating promise of modernity charulata focuses on the libido of charu a bored bourgeois wife elegantly played by madhabi mukherjee ray sets the story in calcutta in the 1880s charu is married to bhupati the publisher of the progressive journal the sentinel similarly to rays grandfather he smokes a pipe uses english phrases and is very devoted to the publication of his journal however he completely ignores her presence as she is left alone in her golden cage just like her birds instead he has hired an english teacher to educate charu in english songs and good manners nevertheless his perfect bourgeois world is shattered in a kind of penterian way by the arrival of his younger cousin the sensitive carefree and poetic amal with whom charu falls in love objects of modernity charulata charulata opens silently almost indifferently with english credits aimed to european audiences as in devi then the beautiful sound of rays sitar playing a rabindranath tagore slowsong musically introduces the audience to the slow and elegant rhythm of the film and opening credits ray masterfully superimposes on the foreground a closeup image of the hands of charu holding a sewingneedle as she crochets a piece of white fabric stretched on a circular wooden frame embroidered with the letter b presumably for bhubati the name of her husband as she cuts the thread with her mouth the camera zoomsout to middleshot that reveals her sitting on a heavily decorated european bed as the clock starks four she calls for her servant but he does not respond she then begins to walk in the long corridor of the upper house followed by the camera while continues calling for her servant brojo are you deaf its past four take the master his tea to his office where he is working she then turns around and walks towards the camera as she tenderly holds and looks at the embroider on which the english capital letter of her husbands name is inscribed she looks as if she is thankful for the life he offers to her then the sound of a crow offscreen a bad omen interrupts her meditation ay hush she shouts at it moving toward the balcony to keep it away from the house she then looks back at her husbands initial letter tenderly held in her hands but as she walks back to her bedroom and sits on her bed she suddenly looks bored charus movement in the house contextualized through a slow moving series of tracking and panning shots reveals the miseenscene of the entire setting which ray has divided into separated spaces between inside and outside areas such as the inside bedroom of charu which leads through the narrow corridor to the outer area of the balcony facing the internal garden her husband has his own space the office in which he spends most part of his day while the servants live separately downstairs as in the english victorian houses of the 19 th century ray further underlines the architectural similarities to a european aristocratic house by the heavy almost suffocating decoration of the rooms with european objects the clock a mirror lamps photograph frames wall paintings the square bed the furniture and a book left on her bed which attracts charus bored attention she picks it up and moves to another space through the balcony to the living room situated opposite her bedroom followed by the camera that takes the audience in a house that feels like a maze a labyrinth in which communication and vision is blocked by a series of small rooms bigger rooms and heavily decorated corridors as charu enters the livingroom walking towards a shelve with books the camera zooms into a closeup of her face and with a reverse angle shot a closeup of her fingers searching the book titles while singing the name of the author she is looking for bankim she finds a book with its title written on its cover in golden letters in bengal kapaalkundala she picks up the book firmly holding it in her left hand and with her right hand she then firmly closes the glassy frame of the book shelve which makes the viewer realize that her figure in the previous closeup was distorted because of the glass placed in front of the camera by closing the frame her reflection becomes clearer as she stares at the book hesitantly wondering if she should pick it up suddenly a hypnotic and repeated sound of a small timpani can be heard coming in from the window the sound suddenly changes her demine as if it is calling for her convincing her of her intentions the indecisive expression on her face is suddenly but always elegantly replaced by a reassured and confident smile settled into her now focused interest for the books content she then turns around in another reverseangle shot as the camera follows her along in the rooms and the corridors of the house but this time she sings loudly the bengali verses of the book she holds in her hands and eyes it is as if this book makes her forget of her complete surrounding isolation and loneliness she then slowly walks towards a shut window to see who is playing the timpani like a prisoner she uses a set of small binoculars originally designed to watch european opera to see through the shut window frame which looks like an old wooden cage with her binoculars she can see an old blind beggar with two monkeys basking on the street as he walks off the limited vision of the narrow frame of her binoculars she changes her focus of attention to other street sounds from the other side of the small room watching again through the window frame people passingby her gaze follows a middleaged man walking in the hot sun carrying a closed umbrella like the stereotype of an englishman an image that makes her smile but then in a longshot she slowly turns around moving back in the living room looking again unhappy and bored between the closed window and a victorian couch there is an old table with an expensive but empty vase on it as she smoothly holds on the luxurious couch she turns around staring at the heavily decorated but emotionally empty room while her finger nervously playing with the binoculars she looks at the lavish surroundings with a kind of soft bitterness one that has replaced her previously reassured smile at the sound of the beggars timpani following tagores slow rhythm of his musical score charu slowly walks towards a grant piano opposite the windows of the living room as the camera continues to track her movements in the house she stops in front of a grand piano sits on the pianostool and then out of boredom hits two disinterested notes the soft sound of the notes stops the slow musical narrative of tagore followed by absolute silence only to be interrupted again by more noise coming from the street as charu aimlessly wonders with the pair of binoculars in her hands surrounded by victorian furniture a french mirror a clock a romantic painting of venus the frame of her husband hastily passesby in front of the camera fast and outoffocus at the background he does not even seem to acknowledge her presence this upsets her and she starts to following him bhupati returns unaware of his wifes feelings passingby without even looking at her a pipe in his mouth wearing glasses and a long academic beard and reading from a book she suddenly hears again the sound of the beggars timpani outside from the street that gives her new confidence and brings back her smile in the next sequence bhupati announces the visit of his cousin amal the passionate and romantic patriot whose visit will change her life forever in this yet another epic opening sequence ray uses heavily symbolism to address the audience regarding charus private life for charu the binoculars offer a new way of looking at the world in relation to her perception of herself and positioning in that world they offer an alternative escape from the bounds of home to the world outside they give a modern way of looking at the world from a distance they offer her the means of escaping the masculine world that has imprisoned her into this materially decorated but spiritually emptyhouse in which she is placed by her liberal husband this prem or the urge of forbidden love to transgress the social norms that oppress someones being was one of the favourite themes of tagores stories it is in transgression that one becomes a kind of process of individuation in jungs terms charu has to transgress the miseenscene of the house that surrounds her in order to rediscover her lost archetypal self like doya in devi the imported mirror upon which both charu prepares for her husband is a symbol of european adjustment based on the internal and external world of male desire the prem seen as imported from the west similarly to binoculars and french mirrors is expressed as the secret feeling of charu for amal and manifested in her gaze towards him ganguly highlighted the power of her forbidden gaze as the means of giving her agency charus playful eye subverts the norm of the submissive look of doya in devi yet in the end of the film the promise of emancipation is proved to be an illusion just like the false promise of the romantic prem rays realization of the destructive powers of sexuality one that associates uncontrolled sexuality with animality conversely portrays women as constantly tempting men away from the path of reason and morality this rationality morally subordinates women by placing them in the house in which they are meant to be controlled spivak discussed tagores short stories along with the constitution of the feminine subject in colonial vernacular literature making a parallel connection of tagores use of the romantic motif prem to teaching english to indian students which makes the use of the english language feel like a burden ray visualizes charus burden as an entrapment within the false premises of modern age despite ganguly praising ray for taking the womans point of view he highlights charus precarious privacy we sense how her space is invaded constantly this emphasis on a womans precariousness is in essence what stereotypically defines women in this context despite the emancipating theme of the film the forbidden gaze does not give agency to charu but rather confirms the stereotypical division of space in terms of female internal and private spaces against male external public spaces this reaffirms the conventional framing of women as representing the privacy of the group on the cultural basis of sexuality and gender as manifested in terms of private and public spaces ganguly expands on charus visual entrapment to the audience gaze in fact all the ambivalences of charus position as gazer and being gazed at are encapsulated by the camera as it spies on her and defines her predicament as a woman always under surveillance but powerless to retaliate in our privileged position we feel empowered by the mere fact that we can see her or rather spy on herwhile she cannot rays framing of charu thus illustrates the voyeuristic scopophillic point of view in laura mulveys terms which characterizes the mainstream dominant phalocratic camera in the context of pleasure as sexual politics charu as well as other female characters in rays films such as doya in devi labanya and monisha in kanchanjungha arati in mahanagar sutapa and bimala in gharebaire are portrayed as entrapped by and within a masculine world divided by gender in terms of private and public female and male spaces respectively females are forbidden to enter into the public sphere and instead they are portrayed as being entrapped in the minds and eyes of their fathers brothers husbands that is within the scopophillic perception of the audience itself the binoculars amplify charus socalled precariousness and her entrapment in a world dominated by male vision which bring her close to the forbidden world not allowed experiencing or touching this kind of social imprisonment visualizes the predicament of modernity as a reductive ocularcentric process increasingly reified closed restricted narrowed tightened distorted and destructively fixated in representations of self of others of knowledge truth and realitythat interpret the visible world by imposing confrontations of opposition between subject and object charus absolute loneliness echoes this paradoxical alienation from a world that increasingly comes closer to us and yet is further than ever a home from which she is alienated like a stranger like the lost uncle of agantuk ray further developed the feeling of entrapment in films focusing on contemporary social issues with his calcutta trilogy sunil gangulis pratidwandi sankars seemabaddha and jana aranya ray made pratidwandi four years after the naxalbari uprising in 1967 in west bengal it anticipated a decade of political and economic turbulence the wars with pakistan and china and the polarization of india in political extremes from ultranationalists to maoists this period of terror culminated with the betrayal and assassination of indira gandhi by her sikh bodyguards who were fighting for a separate state of khalistan in october 1984 rays films reflect upon times of collective disillusionment with the unfulfilled promises of nehrus project democracy as political oppression alongside the dismantling of old family structures the increasing feeling of personal isolation and desperation in overpopulated alienating urban settings and the rise of inequality unemployment street violence and nostalgia for a lost imagined past politics of inequality pratidwandi rays angriest film pratidwandi portrays the journey of siddhartha a young and passionate modern buddha walking aimlessly up and down the streets of the new calcutta in search for a job large sections of the film take place in the oppressive miseenscene of public offices where slowpanning longtakes portray the desperate faces and tired bodies of silent unemployed men pointlessly waiting in the queue for a job it is a collective form of castration as their shakti is never revitalized or set free echoing doyas and charus respective entrapments instead in the unemployed men of pratidwandi are socially and economically entrapped in the impersonal bureaucratic state of massive unemployment this collective sense of alienation is felt by siddhartha who observes the new calcutta as a dislocated wonderer himself alienated both from himself and from the world ray expresses this sense of dislocation in the sequence portraying siddharthas vision in a temple as he aimlessly gazes at some american tourists fascinated by a holy cow while smoking weed next to beggars dying of hunger siddharthas gaze is lost in his own social invisibility in this liminal state of mind his visionary experience begins with a nightmarish vision of modernity in the form of exoticism hunger makes him see the same nightmarish vision ray had in previous films it is a series of juxtapositions of nightmarish caricatures of an aboriginal elder juxtaposed to a hindu priest and then to a guru an image of a young man wearing makeup precedes exuberant jumping dancers followed by another guru in clownish makeup holding a cheap paper reproduction of shivas poseidons triton an image of a voodoo priest drinking from a bottle closing with an image of an old lady begging the exuberant dancers moving without rhythm without aim without reason this is the exact vision a grotesque image of globalized modernity one that charu in charulata and arati in mahanagar also share in their respective visions a nightmare possibly shared by the director himself the second part of siddharthas vision slowly superimposes into the calm and lyrical view of the sea horizon and then the countryside the place where siddhartha yearns to return the forest of pather panchali as in rays previous films devi charulata and mahanagar in pratidwandi siddharthas vision depicts the moment of his selfrealization and enlightenment the moment of individuation in jungs terms referring to the process by which one becomes an individual that is a separate indivisible unity or whole in the end siddhartha realizes his dream and abandons the city for the countryside which is a move that echoes a general feeling of disillusionment with modernity and urge to return to agriculture here again ray connects the inner and outer worlds of his hero as through his psychological changes and pressures he reflects upon the wider socioeconomic counterprocess to urbanization that of decentralization ray expresses his critique of urbanization as a repeated nightmarish vision of a cosmopolitan grotesque urban circus where youth unemployment criminalization of immigration privatization of social services the military and the health system inequality and discrimination violence and drug addiction alienation and poverty are all globalized social deceases back in my trip to kathmandu in april 2012 after i managed to break out of the sacred hanumandkoka durbar square a protected world heritage site where the khumari an eight year old girl was exhibited to tourists as the living goddess i saw another kathmandu burning in anger daily protests frequently take place as in a majority of young people call for a more democratic system but instead they are dealt by riot police the same year in kolkata there were protests and demonstrations over the eviction of people living in slums to be rebuild in the name of progress 1642012 athens cairo london birmingham madrid paris delhi kolkata kathmandu tehran los angeles buenos aires johannesburg and the other melting pots of a world on fire where youth unemployment criminalization of immigration privatization of social services the military and the health system discrimination violence drug addiction alienation and poverty are all global social deceases for the youth today like siddhartha in pratidwandi the promises of a new world were broken despite the enthusiastic celebrations of the beautiful world in tv adverts bombarding them with fake smiles and false degrees by the end of the 1970s and in the 1980s rays cinema moved towards grand historical narratives as in his adaptation of premchands shatranjkekhilari as already discussed in relation to devi charu and pratidwandi ray generally associated sexuality to politics in shatranjkekhilari he further associates male impotence with selfdelusion of characters who fail to take control of their history due to their cowardice indecision in this context tagores prem stories charulata and gharebaire filmed twenty years later offer powerful political allegories about the time they were filmed charulata filmed in 1964 reflects upon the collective disillusionment with nehrus project of modernization through the character of bhubati who fails by his own expectations on the other hand through the passionately patriotic character of sandip gharebaire makes a parallel association of the swadeshi movement with the rise of ultranationalism in the 1970s along with the emergency state imposed by indira gandhi in 1975 the swadeshi was the first nationalist movement following the foundation of the congress in 1885 the movement reacted to the british interference in indian affairs particularly regarding the division imposed on the local population in terms of class and religion which they saw as responsible for extreme poverty that instigated a general social unrest the swadeshi promoted a return to indian culture while calling for the massive boycott of all foreign products ironically despite being a byproduct of postcolonialism the swadeshi movement portrayed itself as antimodernist targeting global trade gharebaire makes clear however that despite the movements promises the working people and particularly traders would not support such a move and fall for the nationalist call a new era began as india along with the rest of the world was rapidly opening up to the neoliberal world market amartya sen has discussed how in the process of globalization inherited forms of inequality initiate or evolve further categorizations in terms of consumer choices and privatization on the basis of which more separations are built the importance of the distinction between seeking equality in different spaces relates ultimately to the nature of human diversity it is because we are so deeply diverse that equality in one space frequently leads to inequality in other spaces new culturally naturalized categories of the mind based on existing established categorizations in terms of class gender ethnicity religion economic status political party color political party football team car house profile and style are relentlessly born reborn evolving revived forgotten mixed fused and discarded in a world built on massive debt the old and hateful ideals of purity are nowadays institutionalized militarized professionalized and airconditioned for the entire world becomes increasingly castsized however rays humanism tells us that this world belongs to us we are the world in the mist of burning plastic rubbish death and happiness walk handin hand for human touch cannot exist elsewhere but in the here and now in pratidwandi portrays moments of sudden terror and social disorder such as the bombing of a cinema full of spectators juxtaposed to scenes that show unemployment and deprivation in this nightmarish world siddharthas visions are the only means of escaping poverty and inequality he is an anonymous young buddha who is aware that in the city his life is limited his shakti is blocked and anger is let loose and yet against this predicament a scene from the film encompasses the entire spirit of ray it shows a mob attacking the owner of a mercedes car because the careless and rich driver had just hit a little girl on the street siddhartha joins the mob that tries to lynch the driver yet as he looks at the back of the car he sees another little girl in shock and tears she is the daughter of the driver looking at her father being beaten up on the pavement it is this kind of double perspective that makes ray look as if he is apolitical meaning an auteur who never takes a political side and rather chooses to keep a distance in the form of the detached perspective of the apueye however i would argue that rays apolitical stand is a fusion of worldpolitics with the tranquil philosophy of inaction a type of aristotelian andor kantian politics both personal and universal this kantian philosophy is ethically reflected upon practical and social matters including the importance of access to education gender equality access to jobs and public health conclusion humanism as a critique of modernity following max webers critique of modernity as a process of wealth accumulation hannah arendt highlighted a collective feeling of alienation from the world satyajit rays filmmaking also illustrated the paradoxical condition of the modernity being both unified and alienated at the same time through his outcast characters such as doya in devi charu in charulata siddhartha in pratiwaldi and himself in agantuk for arendt this form of personal alienation was the result of the rise of the impersonal bureaucracy the banality of evil in her words within an amoral capitalist economy under the modern capitalist mode of uncontrolled production the new modern world with all its malice poverty unemployment and social indifference replaced the two main traditional organisms of society that is family and private property that preserved social solidarity pp 254257 the resulting sense of alienation and unsatisfactory longing stigmatized several of rays characters from apus mother to charus loneliness kalikinkars sexual frustration to siddharthas social alienation their visions and psyches enriched with jungian archetypal symbolism reflect upon the collective consciousness and the historical consciousness of the respective time and place of the epoch the films were produced in this sense the director auteur becomes a charismatic historian of a personal world history whose visions consist of a series of juxtapositions of gazes rays films culminate an epiphany of perspectives from the childhood curiosity of apus eyes to the sense of imprisonment from the perspective of charu or the frustration and disillusionment felt from the perspective of siddhartha in this context rays style is that of a childs play as in bhaktins definition of polyglossia a multilayered and multivocal open arena of imagined subjective point of views and perspectives which articulate personal histories of change and exchange appadurai and breckenridge developed bakhtins concepts of intertextuality and polyglossia into the notion of interocularity the latter refers to the complex relation between what is perceived to be local and what is perceived to be global via crossreferencing in this context appadurai and breckenridge contextualized public culture in south asia as a heterogeneous arena in which new ideas are formed and performed outside the modernist presumptions of hybridity through those eyes and dreamlike experiences ray allows us to see his calcutta and through it his world through the eyes of his characters these personal journeys in the world allowed us to learn more about ourselves in relation to others through our positioning in this everchanging world society rays evolution in perspectives and ways of narrating personal stories echoes the current anthropological thinking about the world and its relevance to this historical moment in their essay on the historical imagination the comaroffs highlighted the missing gaps in the construction of historical narratives which point to the relations between fragments and fields that pose the greatest analytic challenge they pose the question how then do we anthropologists connect parts to totalities how do we redeem the fragments how do we make intelligible the idiosyncratic acts lives and representations of others the historical awareness of satyajit ray as an auteur shows us a way to connect to the imagined world picture out there and even more importantly get to know its real terms it opens up the field beyond the malinowskian miseenscene by following the imaginaries of knowledge makers who have preceded the ethnographer are what the dreams of contemporary fieldwork are made of that stretch ethnography beyond the physical and material limits of the traditional field into the world system in this emerging context satyajit rays work should be reevaluated as ethnographically valuable offering an experiential world perspective into his india through the juxtaposition of perspectives and personal narratives of his characters in this sense ray is a charismatic amateur anthropologist in the kantian sense of pragmatic anthropology offering a cosmopolitan history of kolkata one that is more accurate andor insightful than sterile ahistorical appropriations of postcolonized india by professional anthropologists and other travellers such as the tourist caricatures as portrayed in pratidwandi anthropologically rays world cinema anticipated the third space of ethnographic imagination inbetween great historical events and grounded truths picked from the field back in 1986 marcus and fischer edited a volume of essays that focused on the dynamics of culture in anthropology by redefining the vocation of anthropology as a cultural critique a decade on amartya sen argued that rays sense of humanitarianism culturally challenges preconceived ideals of a european humanitarianism which took the the form of a progressive modernity he pointed out that rays films share to varying extends a wellarticulated antimodernism rejecting in particular western forms of modernization ie our modernism nowadays watching rays films as set on the margins inbetween his bengali identity european education and indian culture reveal channels of communication between presumably opposite cultures whist questioning the orientalist distinction between east and west for sen … the issue can be discussed only in dialectical terms the characterization of an idea as purely western or purely indian can be very illusory the origin of ideas is not the kind of thing which purity happens easily the rigid opposition between east and west in terms of the european enlightenment echoes anthropologys legacy as its byproduct with naturalized ethnocentric dichotomies such as primitive and civilized authentic and hybrid modernity and tradition history and myth science and magic religion and occult and so on within a polarised contextualization of cultures which denies the historical reality of networking and exchange from which cultures emerge in the first place as a dynamic agent of social change modernity and its humanist values are both misconceived to be exclusively european in terms of civilization social progress economic development conversion and the like yet as early as 1919 max weber questioned progress in the face of industrial death following ww1 … because death is meaningless civilized life as such in meaningless … progressiveness in rays films modernity is not visualized as a static condition that separates us from them in terms of progress progress scientific or otherwise rays cinema as a whole echoes kants ethics without a universal appropriation of humanist values progress industrial spiritual or otherwise is simply not progress rays films are still relevant today if not even more relevant than the time they were made because they reflect upon the human condition in our transition to a world society referring to the the totality of social relationships linking the inhabitants of earth this return to the kantian anthropological idea of studying fiction as a means of knowing the world in relation to our positioning in the world turns inwards worldsubjectivity it is a feeling springing out of kants definition of pragmatic anthropology as the practice that contributes to the knowledge of the world in our personal universal quest for world cognition welterkenntuisse furthermore the reevaluation of satyajit rays films from a world perspective serves to the expansion of the ethnographic field beyond the malinowskian mise en scene into the evolution of the world system the turn to fiction has immense implications for fieldwork which are not the focus of this essay but maybe further investigated in the future kant expressed this feeling of belonging to the world in his essay focusing on the idea for a universal history with a cosmopolitan purpose 1784 the pragmatic anthropological effort to rewrite an anthropocentric universal history based on personal memories and narratives inevitably redefines and reinvents the discourses of history and anthropology in interdisciplinary ways from an anthropological perspective the study of history is not the study of the past but that of the future an incomplete force of potentiality in the urge to dream and imagine a better future for humanity as a whole by returning the stranger back to his philosophical roots the perspective of the apus eye then contains the energy of wanderlust or what plato defined as the beginning of philosophy to thaumazein wonderment admiration rays films are a testimony to this feeling of belonging to the world as a means of making it even a better one

the visionary satyajit ray is indias most famous director his visual style fused the aesthetics of european realism with evocative symbolic realism which he based on classic indian iconography the aesthetic and narrative principles of rasa the energies of shakti and shakta the principles of dharma and the practice of darsha dena darsha lena he incorporated these aesthetic elements in a selfreflective manner as a means of observing and recording the human condition in a rapidly changing world this unique amalgam of selfexpression expanded over four decades that cover three periods of bengali history offering a fictional ethnography of a nation in transition from agricultural feudal societies to a capitalist economy his films show the emotional impact of the social economic and political changes on the personal lives of his characters they expand from the indian declaration of independence 1947 and the period of industrialization and secularization of the 1950s and 1960s to the rise of nationalism and marxism in the 1970s followed by the rapid transformation of india in the 1980s through the eyes of his characters rays films reflected upon the changes in the conscious collective of the society and the time they were produced while offering a historical record of this transformation of his imagined india the india that i got to know while watching his films an india that i can relate to the paper highlights an affinity between rays method of filmmaking with ethnography and kantian anthropology for this it returns to the notion of the charismatic auteur as a narrator of his time working within the liminal space inbetween fiction and reality subjectivity and objectivity culture and history respectively in order to reflect upon the complementary ontological relationship between the charismatic auteur and the role of the amateur anthropologist in an everchanging world

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introduction physical activity and exercise are two examples of rapid lifestyle changes during the pandemic people have been compelled to stay home due to the closure of fitness facilities and public parks disrupting their daily routines and affecting their exercise activities thus practical coping skills psychological resources and regular physical activity on the other hand might be beneficial in dealing with such healthrelated issues during the coronavirus disease 2019 pandemic longterm covid19 social constraints significantly affect the body makeup of young badminton players the limited availability of specialist facilities technical coaching sports science assistance and medical personnel have constrained athletes daily activities including training and rehabilitation ambrozy et al found that covid19related sports club closures and physical activity restrictions decreased players fitness and increased their body mass the athletes health and resistance to illness suffer and they perform poorly in subsequent competitions a study by silva et al found that young badminton athletes who stopped training for eight months due to the covid19 pandemic but resumed four months earlier than those who took a yearlong break had a decrease in fat mass and an increase in fatfree mass this alteration affects the quality and quantity of training isolating athletes from their daily training in traditional preparation locations and increasing concern about the future andreato et al found that technological psychological and physical harm is inevitable lockdown measures have also limited access to sports facilities and highintensity training for lowincome and male athletes the correlation shows that this modification increases stress female athletes had more mood disturbances due to perceived stress and unstable psychobio social situations than male athletes during a lockdown females were more likely than males to feel apprehensive and vulnerable athletes use social media to learn about virtual fitness tactics and online workout training during covid19 confinement people used information and communications technology 15 more likely for homebased fitness and physical exercise on social media and mobile apps this predicts more social media and mobile app use for home workouts cinthuja et al discovered that keeping a healthy body mass index and practicing improves badminton skills thus badminton players gain no advantage from playing other sports although previous study has shed light on the negative impacts of the pandemic on various groups levels of physical activity and mental health however there is scant research in understanding the experiences of middleaged badminton players when they are confined to their homes due to pandemic thus this study examined the challenges and opportunities among middleaged badminton players faced during home confinement methods design the researcher sought solutions to the abovementioned difficulty and justified and met the studys aims researchers applied a descriptive exploratory approach as the research method of the study this study also involves interviews and a nonparticipant observation method that allows the researchers to evaluate the players performance the researchers in particular used descriptiveexploratory research to comprehend better an existing problem that had yet to be well explored and characterized participant the participants of this study were six middleaged badminton players based on the following criteria they must be constituents or residents of iligan city middleaged badminton players with more than five years of experience competing in any tournaments with 21 the level of expertise the data was gathered entirely in person through semistructured interviews and nonparticipant observation the researchers employed purposive sampling based on specific criteria to pick individuals data collection procedures data provides information about a phenomenon any empirical research requires systematic data gathering and analysis a research study must have sufficient data collection procedures so that specified study variables can be effectively assessed and reliable conclusions can be formed this research is based on a purposive sampling technique the researchers personally administered the interview and directly observed the players the researchers individually interviewed and observed the players this studys data was acquired by obtaining research venues and participants executing a pilot study and gathering information this study used semistructured interviews and nonparticipant observation researchers interview participants to identify their challenges and rising opportunities under home confinement the researcher delivers a consent form introduces themselves and discusses the study before the interview they discussed and secured the studys confidentiality and ethics after selecting their subjects the researchers were fascinated by what they learned the researcher observed each respondents performance to see if home confinement had affected their physical performance as middleaged badminton players the results will be analyzed after the interviews have been successfully conducted and followed by an observational method this data becomes the basis of thematic analysis and interpretation data analysis descriptive exploratory research methods like interviews and direct observation allow researchers to employ thematic analysis to evaluate experiences ideas and actions across a data set they were transcribed coded and interpreted interview guide data the thematic analysis classifies and interprets emergent themes based on frequency they are grouping comparable words and phrases to determine relationships these categories are replaced and reevaluated the analysis involves identifying relevant keywords and comments from transcribed interviews results and discussion the researcher selected the themes of this study through data analysis which was taken from the participants responses and transcripts that were structured with the research objectives these themes were utilized to identify middleaged players primary challenges and opportunities themes the researcher selected the themes of this study through data analysis which was taken from the participants responses and transcripts that were structured with the research objectives these themes were utilized to identify middleaged players primary challenges and opportunities table 2 presents the various constructions of themes and subthemes from the studys data as covid prevails badminton players are confined at home for a while the participants in the study have experienced and recognized these challenges that can affect their performance in playing badminton the study participants identified two pressing challenges they encountered during home confinement 1 health risk factors 2 barriers to improving skills and the first challenge the participants discussed when they experienced home confinement the health risk factors which they identified poor lifestyles and seclusion anxiety and stressinhibiting factors that affect their health domains the second challenge the participants identified as the foremost challenge is the barriers to improving skills wherein insufficient time and practice were believed to be the primary concerns affecting their skill improvement healthrisk factors health risk factors on the other hand involve health changes the first subtheme is essential for players since health can affect performance practice workouts and games put athletes bodies under tremendous stress consider the body a machine for health peak performance requires meeting physical mental and emotional needs anxious players cannot perform well players must know their bodies demands and focus on nutrition mindfulness and other wellness techniques to perform well people must take care of themselves home confinement denies participants freedom and selfdirection for instance the need for autonomy does not mean a desire to act independently of others instead it is a need to act with a sense of choice and decision even if that means conforming with others or events participants of the study have observed that home confinement is also targeting their health and lifestyle which affect them as a player in terms of their skills performance not being physically active might lead to any life risk conditions there has been a tremendous increase in the adaptation to a poor lifestyle many individuals think this is harmful to their health and should be an intervention step studying this condition aims to determine what causes people to live an unhealthy lifestyle hence being confined at home can lead to sedentary feelings that a participant experienced and revealed that this is a significant challenge during the pandemic barriers to improving skills understanding and overcoming skill improvement hurdles may assist players in enhancing physical activity learning and performing are different regardless of talents tactics or match chances badminton players require physical training to increase their general fitness the studys participants see skill improvement barriers as one of the biggest challenges during the pandemic learning and improving badminton abilities have made people avoid going to court or doing more complicated activities in badminton as in any sport repetition is vital to becoming a better player but home confinement hinders participants skills making them struggle and deteriorate time and practice are needed to meet the bpnt of competence which requires mastery over ones environment and new skills sdt researchers initially studied competence to explain how extrinsic verbal praise could boost intrinsic motivation players fear this type of task because it drains their skills the top two issues identified by participants were health risk factors and barriers to improving skills due to being duped participants are adopting destructive lifestyles and trying to preserve good ones which makes them doubt what will happen next participants prefer resting and eatingno sports involvement da silva santos et al predicted that athletes during the covid19 pandemic would have poorer sleep measures more excellent sedentary time and lower pa silva et al found that young badminton athletes who returned to daily training four months earlier than those who stopped for a year due to covid19 social restriction had lower fat mass and higher fatfree mass but no significant differences in cardiorespiratory fitness nutritional behavior or mood state response proficiency they emphasized that social constraints on athletes cause physiological and psychological concerns the covid19 pandemic increased anxiety ocd and sadness in athletes lockouts worry stress depression and dissatisfy badminton players they were lonely especially badminton players pandemiccanceled tournaments were noted they feel lonely because the global health crisis forces house confinement and badminton is just a sport pagaduan et al observed that household lockdowns decreased exercise and sports these restrictions canceled or postponed the philippine national games southeast asian games and asean para games the pandemic has taxed athletes and the public emotionally socially and physically athletes training and recovery were hampered by a lack of specialized facilities technical coaching sports science assistance and medical experts sports are vital to pandemic containment as shown by the cancellation of badminton basketball football and the olympic games thus participants were affected training and drills help participants use their skills homedeceived people need more training space and execute poorly the limitation also makes them do poorly compared to their peers in typical curriculum or advanced training participants struggled but used it which may have helped skill development participants did not feel accessible effective and connected home confinement opportunities while middleaged badminton players are confined at home for a while the participants in the study have experienced and recognized these opportunities to improve their holistic badminton ability which will develop their performance in playing badminton considering the various challenges middleaged badminton players face they still see its positive aspect in connection with home confinement the study participants identified two opportunities during home confinement 1 self improvement and 2 physical and social wellness 1 self improvement efforts to improve knowledge prestige or character the drive to improve in all facets of life homebound people may become sedentary this limited engagement may adversely affect athletic skills there are benefits to home confinement such as strengthening badminton skills due to confinement restrictions it is hard to improve talent the study participants reported that online lessons and webinars helped them understand the sport and themselves they learned a lot about postincarceration skills and tactics online however players have the selfdetermination to seize possibilities because of how they handled problems participants in this study recognized an opportunity to improve their abilities the players learning materials allow them to continue learning new knowledge abilities and practices when confined at home modern technologies entangle formal and informal learning and learners are expected to use ict for learning actively online learning resources allow informed use and construction of a learning environment that meets their needs consistent practice involves repeating a task under the same conditions competence includes both talent and the mindset of an athlete it requires selfconfidence and studying to improve in sports and life competency is essential competence promotes confidence in athletic performance selfconfidence encourages skill development most participants have satisfied the urge to feel competent in interactions with the environment demonstrating their selfdetermination to overcome the world health problem under home confinement physical and social wellness physical wellbeing involves a persons nutrition exercise and health habits much evidence on the relationship between physical activity and health shows that physical fitness lowers sickness development and delays or prevents disease progression social wellbeing comes from nonfamily relationships peer support improves happiness performance and wellbeing this study found that fitness management and developed relationships are the most potential for badminton improvement during and after home confinement the label fitness management ensures that athletes or players may participate in sports on the other hand fitness management experts are as passionate about sports as they like about controlling the mechanics of playing sports and exercising personal trainers group fitness instructors gym managers fitness facility proprietors and life coaches are all examples of fitness managers middleaged badminton players have shown that they have this selfdetermination to maintain fitness in sports that can optimize their health in playing effectively on the court participants see these opportunities as very important for physical health they are crucial if corrupted by mental health but then participants claim that this aspect also enhances their performance as badminton players for it affects them positively healthy connections make people happier and more fulfilled healthy relationships reduce physical and mental health issues solid relationships even with significant others boost selfesteem and reduce loneliness this helps the player and others according to the studys theory participants feel meaningfully connected nurturing mutual and selfaccepting relationships satisfy the need for relatedness participants say that studying badminton and thinking about the limits during home confinement strengthens family bonds participants reported opportunities for selfimprovement physical and social wellness during and after home confinement and reasonable changes in their badminton play given their age kaur et al employed social media to learn about virtual fitness and online exercise instruction social media and fitness applications were used 15 more during covid19 confinement they eventually transitioned from gym activities to other exercises which enhanced their mental and physical health participants learned badminton online many badminton players use technology to learn new skills concepts and strategies after being scammed at home however participants are independent in solving problems to improve their skills and feel adequate participants are learning online they watch video badminton tutorials and asian players to learn new methods participants study the basic movements online to help them overcome problems and improve their badminton skills participants enjoy badminton after home confinement middleaged badminton players train constantly after home confinement competence shows selfconfidence athletics improves confidence confidence improves skills home confinement improves footwork stamina and competition enhance others daily footwork and home training precede essential badminton rallies and hand execution the researchers saw middleaged badminton players develop with their new knowledge abilities and strategies home confinement exercise increased endurance and airway management enabling athletes to recover faster after games participants reported weight maintenance and stress reduction stressmanagement selfdetermination creates opportunities the study participants received several valuable opportunities physical social and selfimprovement are available conclusion the studys results showed that the people who took part were challenged at home which affected their athletic success and mental health it was found that their biggest problems were not being able to play the sport not being able to get better at it and having health risks like a lousy lifestyle and feeling alone anxious or stressed the research showed that these barriers and factors harm the problems that middleaged badminton players face this could lead to poor performance and health problems the studys results showed that the people who took part were challenged at home which affected their athletic success and mental health it was found that their biggest problems were not being able to play the sport not being able to get better at it and having health risks like a lousy lifestyle and feeling alone anxious or stressed the research showed that these barriers and factors harm the problems that middleaged badminton players face this could lead to poor performance and health problems their capacity for selfdetermination increased as a result of the pandemic because the players were determined to continue pursuing these opportunities despite the challenges brought on by the pandemic they could take control of their athletic careers and maintain a positive attitude as a result their capacity for resiliency determination and flexibility increased which enabled them to overcome obstacles and maintain their concentration on their goals opportunities presented by pandemics have a significant impact on both the wellbeing and athletic performance of middleaged badminton players understanding the challenges and opportunities of home confinement for middleaged badminton players is important for their physical and mental health during a crisis the article aims to improve sports psychology public health and crisis management by filling the research deficit in this population the findings can help design tailored interventions and support mechanisms to keep middleaged badminton players and other athletes engaged through challenging times theoretical implications in this study the researchers drew an implication on how the studys findings relate to the existing sdt literature the sdt has been widely employed in a variety of research fields sdt refers to human personality and motivation as it relates to how an individual interacts with and is influenced by his or her social environment sdt defines intrinsic and extrinsic motivation and explains how these motives impact situational reactions in several areas as well as social and cognitive development and personality most sdtguided research has also examined environmental factors hindering or undermining selfmotivation social functioning and personal wellbeing although numerous particular negative impacts have been investigated research shows that these disadvantages can be most succinctly defined in terms of opposing the three basic psychological demands as a result sdt studies not just the precise nature of positive developmental tendencies but also the social environments that are hostile to these tendencies based on the results from the participants responses in the study they revealed that they had encountered opportunities despite the challenges they faced during home confinement health risk factors significantly impact the need to feel free and selfdirected this does not fulfill one of the basic psychological needs theory components which involves an individuals desire to have ownership over their actions and feel psychologically independent despite the situation middleaged badminton players manage to look for the bright side of these challenges and identify opportunities they believe that they can exercise their free will because autonomy does not necessarily mean doing things alone people frequently opt to engage in activities with others and what matters most is the sense of making a choice and feeling like it is their own decision with these it results see an avenue of selfimprovement through online tutorials and webinars about the sport the study participants raised that the current phenomena also triggered their mastery and effectiveness in badminton because people like to feel good at what they do this particular bpnt is the growing sense of mastery at a task that engages motivation from within driving the rigorous reflective practice necessary to build competence middleaged badminton players have shown that despite the barriers to improving their skills in badminton because of the insufficient time and practice that cause skill deterioration they still manage to see opportunities from it through constant practice they can address their challenges considering their level of selfdetermination and the influence of intrinsic and extrinsic motivations along with home confinement participants struggle to connect with their peers which will trigger their sense of relatedness in bpnt this sense of belonging might be felt on an interpersonal level it can also be cultivated by connecting to a group or its ideas or aims participants then handled it with the influence of their level of selfdetermination they have developed strong relationships with their family and experienced enhancing their social wellness in the sense of extending social circles among peers and neighbors fulfilling these basic human needs fosters what is known as autonomous motivation this is not an allornothing occurrence rather there are degrees of relative autonomy since extrinsic motivation may be internalized to varying degrees encouraging autonomous motivation improves functioning and wellbeing as evidenced by research findings of middleaged badminton players people who are more autonomous in their behaviors are more likely to persist and feel better overall in sum the findings of this study demonstrated that a persons level of selfdetermination is determined by autonomy competence and relationships with others the basic psychological needs of humans if met have a favorable impact on overall badminton performance as a result these needs should be prioritized for a badminton player to be more effective limitations and future research it is important to note that the findings of this study are limited to a specific group of middleaged badminton players in iligan city and may only be representative of some of the demographic the research may have been biased by its location or badminton community future studies should use more extensive and more diverse samples the studys focus on home confinements immediate challenges and opportunities may not capture middleaged badminton players longterm effects followup studies should explore how these people adjust to lifestyle changes and return to normal after the pandemic future research suggests longitudinal examinations of middleaged badminton players prepandemic confinement and postpandemic experiences help determine their longterm physical and emotional health also future research on middleaged badminton players should be compared to other age groups or sports enthusiasts during home confinement to understand agespecific obstacles and coping techniques better understanding agerelated reactions could inspire demographicspecific assistance initiatives the scientific community can better support middleaged badminton players during home confinement by addressing these limitations and focusing on these future research directions

this study explores the challenges and opportunities encountered among middleaged badminton players during home confinement the study employed a descriptiveexploratory qualitative approach the researcher used semistructured interviews and nonparticipatory observation to collect data from six middleaged badminton players who met the researchers criteria the studys findings revealed that the participants were challenged during home confinement influencing their athletic performance and health condition they pointed out that during home confinement middleaged badminton players encountered challenges that included barriers to improving skills playing the sport and health risk factors such as poor lifestyle seclusion anxiety and stress playing the sport was hindered by limited experience with peers and limited access to facilities and equipment more time and practice impeded skill improvement however the challenges faced during home confinement motivated the players to seek selfimprovement opportunities and enhance their physical and social wellbeing the studys results emphasize the need to recognize the effects of pandemics on middleaged badminton players performance and wellbeing this information is crucial for future research to develop appropriate solutions for individuals facing similar challenges during the pandemic or similar events

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background in 2017 it was estimated that there were 26500 new breast cancer cases in canada and that 5000 women died of the disease 1 ninety per cent of deaths due to breast cancer in canada occur in women aged 50 and over 2 the disease has negative economic impacts not only on family incomes but also on the state and on the public health system 3 indeed in quebec breast cancer ranked fifth in costs for medical services among all types of cancer 4 to detect the disease early the quebec breast cancer screening program provides free mammograms to women aged 50 to 69 years old when they reach age 50 women receive a medical referral letter every two years inviting them to have a mammogram the strategy is to facilitate medical referrals and monitor test uptake since the start of the program in the 1990s a significant decrease in mortality from breast cancer has been observed 5 this decline in mortality is due to screening as well as to therapeutic advances an assessment of the qbcsps impact on mortality conducted by the institut national de santé publique quebec national public health institute showed a 7 to 11 reduction in mortality from breast cancer among women aged 50 to 69 for the years 19982003 after considering improved treatments 5 the qbcsps objective is to reduce by 25 mortality attributable to breast cancer over a 10year period to achieve this goal it is important to reach and maintain a participation rate of 70 among the targeted women however in 2017 only 56 of montreal women participated in the program 6 this is one of the lowest participation rates in the province of quebec where the overall rate is 65 7 possible explanations include the low participation of poor and immigrant women 8 9 10 11 the concept of gradient of inequalities in health is not new in 1980 inequalities in health report of a research working group was published in england 12 the report which introduced the concept of inequalities in health showed that the mortality rate of men at the bottom of the social scale was twice the rate of men in the wealthiest group since then numerous studies 1314 have shown that this observation applies to many health issues in different societies such as incidence of cancers cardiovascular diseases and infectious and other diseases breast cancer is an interesting case though its incidence is lower among disadvantaged women mortality is nevertheless higher among this group 8 15 16 17 in this case the health care system may play a role in inequality as screening strategies might be inadequate for these women it has been shown that more immigrant women die from breast cancer than nonimmigrant women 81819 interestingly screening participation rate is lower among immigrants than nonimmigrants 9 20 21 22 23 this might explain part of the inequality in death rates 816 the scientific literature documents the potential for social inequalities in health when the sole objective of prevention initiatives and health promotion is to improve the health of the population in general without considering equity among social groups or the particularities of specific social groups 24 how to reach women of haitian culture and raise their awareness of the importance of being screened is an important question it is also one of a global set of questions about outreach strategies for many different cultures all with potential barriers to getting screened a study conducted in a metropolitan area showed that 57 of recent immigrants did not join the screening program compared with 26 of nonimmigrants 10 indeed there are various cultural barriers to breast cancer screeningnot to mention language barriersin a diverse range of cultures including for instance southamerican asian middle eastern and african cultures 23 25 26 27 such barriers include distrust towards medical services 2728 fatalism 2728 stigma associated with cancer 2127 discomfort with the potential of being seen by a male mammography technician or physician 2127 countries of origin whose health systems are focused on treatment rather than prevention 1627 cultures where medical services are sought only when symptoms appear 2027 or cultures where people prefer not to know 2728 in the saintléonardsaintmichel district where 55 of haitian immigrants to montreal reside the participation rate in the qbcsp was 377 the second lowest among the citys districts 2930 the haitian community in montreal is a major one its 129000 persons comprise 78 of all haitians in canada 3132 considering the fact more immigrant women die from breast cancer than nonimmigrant women 8 9 10 and that the health care system sometimes plays a role in social inequalities in health it is important to determine whether the qbcsp outreach strategy and its letter the focus of this study might foster this inequality in cooperation with community partners in the haitian community and other ethnocultural communities the qbcsp has used various languages to reach immigrant women via different strategies including dedicated telephone lines leaflets and posters web pages the involvement of community leaders and health professionals publicity campaigns and workshops run in collaboration with community organizations services and the media 33 to our knowledge no research has tested how the main letter which is mailed to all women over 50 in quebec and is written in french or english is understood by women from a major ethnic community the haitian community the main objective of this research was to assess how haitian immigrant women in montreal perceive the mammogram screening referral letter sent by the qbcsp the secondary objective was to evaluate whether the literacy levels of those women play a role in their adherence to the screening program methods qualitative methods were used for the twostep analysis first indepth interviews were conducted with relevant community workers professionals from two different local health community centres and a leading community worker from a haitian community organization interviews were conducted to plan focus groups determine appropriate questions and decide on a strategy for addressing the targeted community the goal of this first step was to understand related cultural phenomena in the haitian community and address key issues pertaining to the disease the selected group and prevention second focus group participants were recruited via a haitian community organization inclusion criteria were being a haitian woman aged 40 to 69 and living in a disadvantaged area in the neighbourhoods of saintmichel or montréalnord which have the lowest literacy levels in montreal the participants recruited were either eligible for the qbcsp or would soon be the neighbourhoods targeted also have high concentrations of haitians 34 literacy levels in these areas of montreal are low we purposely chose not to investigate or consider participants breast cancer history focus groups were conducted to understand womens personal experiences with and reactions to the qbcsp letter 35 according to wilkinson focus groups are a method of choiceparticularly among ethnic minority womento gather data on peoples own meanings of health and illness and have been used to facilitate access to screening 36 to encourage dynamic and interactive discussion each group included 10 to 12 women 37 on average the group sessions lasted one and a half hours the participants opinions feelings and attitudes about mammograms were documented as were their understanding of the referral letter and the resulting level of compliance focus groups were facilitated by one of the authors who speaks creole the language that was used to enhance communication and understanding our research ties in with the consortequity 2017 statement 38 which promotes the reporting of factors that relate to unfair and avoidable differences between population groups 39 in health intervention effects we also build on the method used by the consort team to develop this statement the team drew on patients and key informants knowledge to improve reporting of intervention effects related to health equity 40 in our case the intervention is a screening program and its effects might differ according to outreach level attained among various population groups a plan of topics to discuss was developed and qdaminer qualitative data analysis software was used for inductive analysis of the transcriptions of the focus groups conceptual framework we used a conceptual framework that integrates both the cybernetic model of communication 41 and health determinants addressed in the literature the cybernetic model of communication describes transmission of messages in five steps factors can interfere in message transmission before it gets to the receiver here the interfering factorsthe barriers to receiving mammogramsare social health determinants ethics the project was reviewed by the research ethics committee of the montreal regional health and social services agency and by the research ethics committee of the university of montreal each participant signed a consent form validated by the committee the committee also validated the interview guide setting participants expressed their opinions about predetermined themes overall we adopted a nondirective interview style giving participants flexibility 42 except in cases where their low levels of literacy and education required explanation to get answers in addition breakfast or snacks and monetary compensation were offered data analysis a thorough analysis of the transcriptions from the three focus groups was performed to determine categories using the research projects conceptual framework we performed an inductive analysis and identified categories pertinent to the objectives of this research 43 a preliminary classification established the following categories lack of understanding not understanding a question a concept or the letter sociocultural characteristics expression of beliefs values and attitudes for or against adherence to mammography lack of culture of prevention income knowledge expression of a lack of knowledge or good knowledge of breast cancer or of mammograms health system identification of barriers caused by the health system and suggestions for changes to the referral letter results preliminary interviews permitted an ideal setup of the focus groups better time management and enhanced participation through the use of haitian creole thirtytwo women were met all participants were covered by the provincial government healthcare insurance which fully covers screening and treatment after three focus groups saturation had been reached 44 coding resulted in four categories the internal validity of this research was assessed by interrater agreement verbatim transcriptions were encoded by an external encoder overall the segments were coded the same way by both coders results based on our category definitions are presented here understanding not understanding the letter we observed that level of literacy among the focus groups was low indeed most participants could not read french nor speak the language very well participants repeatedly stated they did not understand the letter one participant who herself had difficulty reading read the letter to the others who could not read as explained in the introduction the letter sent by the qbcsp acts as a referral for a mammogram however the participants did not think it looked like a referral form as intended they were confused about the contents of the letter their questions pointed out the importance of some details omitted from the letter and which need clarification not understanding a question occasionally despite the fact that participants were addressed in creole their answers were offtopic this suggests that the question was not properly understood the researcher noted moments of silence again implying lack of understanding sometimes the researcher had to explain restate or guide the discussion to ensure that participants understood not understanding words the most misunderstood words were mammogram and screening however participants said they understood the word breast but would still prefer the creole translation of the word signs of social desirability there were signs of social desirability when it came to commenting on the health system or the letter participants reported being quite satisfied with the letter and had almost no comments on its content and format despite their lack of understanding this contradiction will be further discussed below sociocultural characteristics sociocultural characteristics favorable to mammography this category included cultural characteristics specific to haitians and socioeconomic characteristics attributable to any disadvantaged group women from the haitian community perceive breasts as a very important part of the female body representing beauty pleasure and maternity these women are not uncomfortable or inhibited when it comes to breasts haitian women recognize the importance of going to a doctor and having confidence in him or her the women said they fear death and feel vulnerable to the disease we will see below that a minority of participants do not feel vulnerable and are not afraid because of their fatalistic dispositions participants expressed the importance of having support from the community especially because they are illiterate researcher do you think that most haitian women understand the letter participants no those who dont will ask someone to explain it translation unfavorable sociocultural characteristics as stated previously some women said they were not afraid of breast cancer i cant be afraid of the disease since its chosen me you cant be afraid because its not you who put it in yourself i have children jesus will not do this to me translation participants stated that their friends do not seem to participate in the program finally a very important social characteristic of these women is using creole as the language of communication participants expressed the need to have a translation of the letters key words so they could understand the main issues presented knowledge presence of knowledge participants were aware of the disease and had enough knowledge to understand that it is serious some referred to the hereditary nature of this disease mentioning that they would feel more vulnerable if they had a family history of breast cancer in addition participants understood that the disease affects all groups regardless of race country of origin or other factors as for the causes of breast cancer some participants said that lifestyle habits like smoking drinking alcohol malnutrition and bad eating habits affected the likelihood of contracting the disease despite having somewhat limited knowledge and though several women were aware of breast selfexamination and knew how to perform it very few participants were familiar with mammograms one participant talked about the reliability of the test she mentioned the falsepositive and falsenegative results as being the main reason why she does not get mammograms along with the anxiety they provoke this segment was also coded as a barrier lack of knowledge some participants openly admitted that they know little about the disease my kids are not like me they know we know nothing about breast cancer translation there were mistaken beliefs about breast cancer and mammograms participants believed that a blow to the breast systematically causes breast cancer they also thought that mammograms could cause breast cancer because of the pressure on the breasts concerns were also raised regarding radiation exposure there was a misconception about mastectomies as well participants thought that one cannot function with a missing breast and that cancer will kill no matter what stress concerning the outcome and challenges posed by the disease was also a concern participants said they would rather not know they are sick because knowing would make them sicker participants said that breast cancer is not a prevalent disease in haiti in fact the who reports that 6 of all deaths in haiti were attributed to cancer in 2010 45 however participants have known women who had breast problems but the term cancer seems to be rarely used when i lived in haiti i didnt know there was a disease like breast cancer i saw several women die when i got here i understood they probably died from breast cancer … in my village in the countryside not everybody thinks about breast cancer translation participants were unaware that breast cancer was inside the breast most of the time and did not necessarily form a lump on the surface they did not know that breast cancer was an insidious disease that one could not feel we noted some confusion between breast and cervical examinations hence the confusion about mammograms participants also did not know the difference between a mammogram and a simple xray we observed that lack of knowledge was also due to a limited understanding of the french language as we handed out the qbcsp letter we observed that the women had difficulty reading and understanding it it should be noted that in haiti french is used by the uppermiddle class only another issue was the concept of mail many people do not have formal addresses in haiti moreover in many villages and neighbourhoods postal service is poor people in haiti particularly in low socioeconomic classes very rarely receive letters by mail health system barriers in the health system participants expressed a preference for haitian doctors so they could communicate in their mother tongue and better express their concerns they clearly stated their apprehension about not being able to explain their feelings well in french or english other health system barriers noted by participants were not having a family physician the false positive and false negative controversy waiting times in hospitals and clinics and the cost to avoid waiting lists indeed in montreal if a mammogram result is of concern further exams are prescribed including ultrasounds however waiting lists for these tests can be very long and only patients who can afford it can skip the waiting period and pay to have it in a private clinic suggestions for the letter the qbcsp sends a letter in french or english since quebec is a bilingual province to better understand at least the purpose of the letter participants asked that the words breast mammogram and cancer be translated into creole the letter is one page long and has five dense paragraphs participants suggested a shorter letter which would look more like a traditional prescription meaning a smaller and less elaborate piece of paper clearly identified as a prescription referral the qbcsp intended to give readers an idea of the size of tumours that can be detected by mammography by drawing a simple dot participants did not understand what it referred to at all and suggested adding a drawing of breasts to illustrate the point and give a better idea of the size of the dot compared to the breast they also suggested comparing it to the size of a fruit overall participants felt that the content of the letter lacked appeal they suggested using simpler more accessible language and shorter sentences so that readers are taken straight to the essential information finally participants suggested promoting mammography and the breast cancer screening program on television and radio during the news because they claim all haitians watch the news discussion study results suggest that the referral letter is an important barrier to getting a mammogram mainly because it is poorly understood by women with very low literacy levels the scientific literature also identifies low levels of literacy as an obstacle to mammography 41 42 43 44 45 46 47 48 49 50 51 52 53 the study reveals additional factors influencing compliance with mammography that are related to a lack of understanding of the letter consistent with previous studies results show that stress related to outcome is a significant barrier to getting a mammogram 1054 according to focus group participants stress worsens the disease so they prefer not to know if they have breast cancer yet stress fear and vulnerability can induce women to get a mammogram since it allows for early detection and saves lives however women do not perceive the benefits of screening an attitude that is not unique to the haitian culture it is common in groups with low socioeconomic status 1455 participants friends do not seem to adhere to the program either this can be attributed to an absence of mutual encouragement from people in their community living in similar conditions an emphasis on the importance of early detection is crucial to increase adherence to the program one way to achieve this would be to have a shorter more focused and convincing letter the indepth interviews allowed us to understand that women of the haitian culture sometimes provide an explanation for illness that draws on religious beliefs disease comes from the devil or from god participants seemed to perceive breast cancer as a disease given by god for reasons beyond their comprehension several studies have found that other cultures also believe that the devil can cause a person to develop breast cancer 285657 the devil is also believed to be the cause of other cancers and diseases in haitian and in other cultures 1625 58 59 60 61 62 since mystical and religious beliefs play important roles in haitian culture this point should be carefully considered to promote mammograms and increase awareness of breast cancer findings differ from those of other studies on immigrant women and their adherence to mammography 52536364 our results show that women in the haitian community do not believe that breast cancer only occurs in particular groups of women but that any woman regardless of cultural background could have breast cancer therefore concerns related to stigmatization of groups that are more susceptible to the disease will not need to be taken into account when promoting the program in this community participants enthusiasm and their mostly positive comments about the letter were inconsistent and contradicted what is suggested in the literaturethat women from disadvantaged backgrounds adhere less to breast cancer screening programs 28 65 66 67 their responses may have indicated social desirability it seemed that participants may have wanted to give the impression that they understood everything one can suggest that this happens in many situations in their daily lives including at the doctors our study addressed several specific points about the content of the letter first it indicates that women in the haitian community are not shy about their breasts a factor that is favorable for mammography they requested that the word breasts be translated into creole in the letter so they can better relate to what is being asked second women did not understand the dot used to illustrate the size of a possible tumour detected by a mammogram to address the issue it could be judicious to include more explicit drawings of a breast tumour to enhance understanding including such drawings would not be a problem since haitian women are not shy about their breasts third the fact that most women in focus groups did not know the meaning of the word mammogram indicated that there is a mismatch between the language used in the letter and the target communitys literacy levels although some women knew what an xray is they did not know that breast xrays existed or that a mammogram is an xray therefore it would be worthwhile to explain the technical jargon in the letter to make the letter clearer for the women in terms of the format of the letter no participant understood that it was a referral it is important that it look like a referral for a test which is usually on a smaller piece of paper andor be clearly entitled pres cription secondly it is imperative to be aware that the mail system in haiti is not the same as in canada women stated that they do not always pay attention to their mail since they are not used to this communication system social desirability was present in participants responses in summary research results show that there is significant lack of knowledge and understanding of breast cancer and mammograms some cultural characteristics can explain the attitudes and beliefs related to this matter however a lack of knowledge and understanding as well as negative attitudes and beliefs about mammograms could be countered by introducing better strategies in the health system especially through the qbcsp referral letter moreover there appears to be a problem with accessibility the health system category indicates barriers in quebecs health care system that cause poor adherence to breast cancer screening and even low utilization of the system also the format of the qbcsp letter and level of language used limit the womens understanding which supports our initial hypothesis strengths this research approach corresponds to an exploratory perspective although the scientific literature acknowledges several barriers to immigrant communities accessing preventive services this aspect of the qbcsp has never been evaluated an important strength of this project is that it was a twostep process indepth interviews notably with leaders of the haitian community which permitted optimal preparation of the focus groups and the focus groups themselves which were designed in collaboration with the leaders the originality of this research project is reflected in the proximity of the researcher to the participants the fact that she is herself of haitian descent and speaks creole enabled her to conduct the focus groups in creole be more culturally sensitive and provide a better interpretation of the results this facilitated communication and expression of details and feelings that participants were ready to share limits social desirability was repeatedly observed in this study the researcher asked the questions in such a way as to try to bypass some social desirability biases common limits of focus groups such as the group effect were detected participants occasionally waited for someone else to respond before contributing their own insights use of focus groups probably led to more homogenized results the vast majority of participants in this study had problems with literacy they were unable to understand the letter which clearly created a barrier to the qbcsps objectives to compensate for this limitation the researcher read the letter to participants so they could express their lack of understanding this may have raised additional issues regarding the letter that may not have come up otherwise conclusions the main objective of this research project was to evaluate the qbcsps strategy of using a referral letter to invite eligible women to have a screening mammogram the main conclusion is that the technical wording of the letter did not match participants literacy levels which created a major obstacle to adherence to the program there is an obvious need for simpler wording as well as a letter in their native language in addition participants voiced a clear preference for haitian physicians which could enhance adherence to mammography to promote a culture of prevention in immigrant communities there must be a more appropriate communication plan that will make them feel confident and safe in light of our results a new referral letter should be prepared and adapted to the targeted community based on the conclusions of the current study qualified haitian doctors who are waiting to have the right to practice in quebec could also be involved in promoting participation in the qbcsp given the good reputation of these doctors in their country they could be trained as spokespersons for the breast cancer screening program in their community social inequality in breast cancer mortality could result from a failure of the health system one might wonder if the referral letter is understood even by native french and english speakers from disadvantaged groups or with low literacy levels this topic could be the subject of further research authors contributions mfr and cf wrote the article based on cfs masters thesis directed by mfr dc added a section to the article and updated the literature review to support the article all authors read and approved the final manuscript funding funding was received from the canadian institutes of health research grant no roh115211 for a study called evidencebased data for public health interventions aiming to reduce social inequalities in health competing interests the authors declare that they have no conflicts of interest

background the province of quebec canada has implemented a breast cancer screening program to diagnose this cancer at an early stage the strategy is to refer women 50 to 69 years old for a mammogram every two years by sending an invitation letter that acts as a prescription ninety per cent 90 of deaths due to breast cancer occur in women aged 50 and over numerous studies have shown social inequalities in health for most diseases with breast cancer a significant paradox arises its incidence is lower among disadvantaged women and yet more of them die from this disease the health care system might play a role in this inequality the scientific literature documents the potential for creating such inequalities when prevention does not consider equity among social groups immigrant women are often disadvantaged they die of breast cancer more than nonimmigrants studies attribute this to latestage diagnosis due to poor adherence to mammography screening programs purpose of the study the main objective of our research is to assess how haitian immigrant women in montreal are reached by the quebec breast cancer screening program and specifically how they perceive the mammogram referral letter sent by the program methods the study uses a twostep qualitative method i indepth interviews with influential community workers to identify the most relevant issues ii focus groups with disadvantaged women from montreals haitian community results a mammogram referral letter from the breast cancer screening program may be a barrier to compliance with mammography by underprivileged haitian women in montreal this might be attributable to a low level of literacy poor knowledge of the disease and lack of financial resources

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introduction the emergence of the internet has revolutionized the way political information is created disseminated and consumed particularly through social networking platforms which have become a crucial arena for political communication given their centrality the circulation on such platforms of political content that appears dubious in regard to its factuality approval rates and political motive has raised widespread concern numerous investigations have indeed uncovered the widespread presence of political content on snps that masquerades as reliable neutral informationthough it aims to discredit opposing viewpoints rather than serving an informative purpose and it is frequently amplified through the systematic use of automated tools and impersonation of accounts such findings have urged scholars to extensively address this alarming phenomenonwhich in this paper is referred to as online propagandaleading to a thriving yet quite disconnected body of literature this fragmentation can be attributed to the interdisciplinary nature of the research itself as well as to the complexity and multidimensionality of the phenomenon it addresses in fact scholars investigating online propaganda not only employ various theoretical and methodological approaches but they also focus on different dimensions of the phenomenon contributing to the disconnected nature of the literature this poses a significant challenge as the absence of a structured and comprehensive organization of the extensive literature generated thus far hampers the interpretation and systematization of findings in relation to previous research within this field as a result the overall comprehension of the phenomenon is jeopardized to address this fragmentation i propose a novel approach to analyze and structure the existing body of literature on online propaganda this approach involves utilizing druckmans generalizing persuasion framework as a unified interpretative framework to organize this scholarly work by adopting this approach i argue that it is possible to systematically identify the various strands within this field of study and recognize their respective shortcomings additionally employing such strategy enables the formulation of new strategies to bridge these research strands and advance our comprehension of how online propaganda operates hence this paper is organized as follows firstly it presents a theoretical definition of the phenomenon under investigation and introduces the gp framework as a mean to consolidate the fragmented literature secondly it examines the different strands within the literature using this framework finally it addresses the limitations of each strand and suggests approaches to overcome them while also establishing connections between the various strands in particular arguments are made in favor of incorporating sociocultural perspectives in both the theoretical conceptualization and empirical evaluation of online propaganda functioning as an effective method to bridge the literature defining online propaganda propaganda is still a muchdebated term in the literature which is often applied in very diverse contexts with different meanings and implications the conceptual and thus terminological entropy characterizing the literature on propaganda is related to the multidimensional nature of the phenomenondo we intend propaganda as a communication practice a public opinion issue or a more general political phenomenonas well as its complex relation with persuasionis one a subcategory of the other or are there structural differences between the two drawing from jowett and odonnell in this paper propaganda is intended as a specific class of communication that involves two actorsa sender and a receiverwho through a process of symbolic interaction use information in an attempt to share meaning although propaganda has important similarities with persuasionhighlighted by the presence of persuasive communication elementsit differs from the latter in one crucial aspect while persuasive and propagandist communication share the same aimie influence a targeted audience into voluntarily adopting a point of view andor a behavior favoring the senders interestthe former is overt about its persuasive intentions while the latter is not indeed propaganda wants to pass as informative communicationwhose only purpose is to create mutual understanding of data concepts and ideas that are considered to be accurate and factbased therefore the major difference between persuaders and propagandists lies in the fact that the former do not want to appear as informers while the latter do building on these considerations propaganda can be therefore defined as a type of communication with a concealed persuasive aim which is pursued in a systematic and organized wayie with a clear and deliberate political strategy to depict online propaganda however a further specification is required indeed the internetand in particular snpshave profoundly altered classical topdown communication models where senderreceiver roles were usually static and unidirectional in fact these platforms have transformed their users into productive consumersor prosumers who rather than being passively exposed to information have an active role in its production and circulation this aspect is of crucial importance for online propaganda as it makes the traditional distinction between propagandist and targeted audience blurred transforming social media users into potentially active campaigners this is why compared to its traditional form online propaganda is participatory as it tries to coopt its targeted audience to actively engage in the spread of its messages this conception of online propaganda is far from being definitive nonetheless it is particularly enlightening as it stresses a fundamentaland yet often overlookedaspect of this phenomenon namely the fact that as a communication practice online propaganda necessarily involves the interaction between two actors a sender and a recipient despite this relational aspect studies addressing online propaganda often tend to focus on either one or the other actor adopting different theoretical and empirical approaches that are rarely in dialogue with each other this has produced a thriving yet quite disconnected scholarship which makes its systematization particularly arduous the lack of dialogue between such approachesand their findingshinders a coherent advancement of the literature potentially jeopardizing a comprehensive understanding of the phenomenon to overcome this issue the following section proposes a systematization of the current scholarship under a common frameworkthe generalizing persuasion framework by druckman the intent is to evaluate different strands of literature on the same conceptual basis to clearly determine the contribution of each approach as well as its limitations and later identify potential strategies to overcome existing shortcomings and bridge the two approaches systematizing a disconnected literature under the gp framework the gp framework was developed to offer a conceptual tool to systematize and draw generalization from the vast but highly fragmented scholarship on persuasion it has been designed to highlight the sources of variations considered pivotal for the understanding of the phenomenon in order to easily identify the connection between different studies addressing persuasion given the incorporation of elements of persuasive communication into propagandistic communication and thethough covertpersuasive aim of the latter the deployment of the gp framework is considered particularly suitable for the systematization task that has been set this framework identifies four core elements in the study of persuasive communication actors treatments outcomes and settings each of them encompasses different components that serve to better specify the aspects addressed by each dimension druckman makes clear that by no means does the gp framework requires researchers to account for all the dimensions identified when investigating persuasive communication but it rather urges them to be explicit about which elements they study and how so that dialogue within the literature can emerge and potential contradictions can be overcome when assessing the literature on online propaganda by means of the gp framework it appears evident that the discontinuity previously mentioned is not only due to different theoretical and methodological traditions but it is also related to different research goals which are reflected in the dimensions addressedand neglectedby the investigations when accounting for these two major strands of the literature emerge the firstwhich we could call supplysideis mostly preoccupied with the question of how people get exposed to propaganda content on snps thus focusing on the process and the motivations behind the production supply and availability of propagandaincluding patterns of exposure to and engagement with such political material as such investigations belonging to this strand tend to study a specific component of the actors dimension namely the speaker completely neglecting the receiver component and consequently the outcome dimension all together conversely the secondwhich can be labeled demandsideengages with the study of the effects that exposure to online propaganda produces on its targeted audience thus concentrating on the mechanisms underlying the persuasion process studies interested in this tend to focus on the receiver component of the actors dimension overlooking its counterpart but thoroughly addressing the outcome dimension instead in the following sections these two approaches will be further examined by means of the gp framework with the aim of better positioning their contributions within the literature addressing their limitations and discussing how theseif not accounted here is an overview of all the components in relation to their respective dimensions actors treatments outcomes and settings as outlined in the following section some authors belonging to the supplyside strand of the literature have discussed online propaganda receivers and outcomes however they have done so in a descriptive way by limiting their considerations to the accounts engaging the most with this kind of political content or by speculating on its e ects without formulating empirically testable propositions for these reasons these componentsdimensions are not considered to be the core focus of this approach formay represent important shortcomings for the sustainable development of the literature the supplyside approach propagandist their aims and their goals scholars adopting a supplyside approach to the study of online propaganda are usually preoccupied with the identification and classification of the political actors involved in this communication practice the aims underlying their actions and the strategies implemented to accomplish themall while considering the specific features of the different political contexts in which such a phenomenon arise as such these investigations mostly focus on three dimensions of the gp framework namely actors treatments and settings though they do not address all the components these dimensions encompass most notably they devote most of the attention to the speaker components of the actors dimension concentrating research efforts on the identification of the type of speakers involved in the production distribution and proliferation of propaganda on snps as well as the motivations behind their actions indeed this stand of the literaturewhose research agenda has been largely stimulated by the computational propaganda project at the oxford internet institute and the observatory on social media at the indiana university is mostly preoccupied with uncovering the identity the location and the motives of online propagandists as well as their organizational practices and methods of dissemination this workoften complemented by reports from nonacademic sources such as journalists intelligence agencies and snps themselveshas provided important insights on the characteristics of both online propagandists and the proliferation patterns of their messages studies on the production and supply of online propaganda have uncovered how this is a widespread communication practice implemented by numerous actors around the globe who are very diverse in terms of identity organizational structure and motives ranging from state and intelligence agencies to teenage groups and political extremists these speakers have very different aims for propagating their messages some are driven by economic reasons while others have political it is important to note that studies exploring how the online media system and its ownership structure a ect the production circulation and consumption of information on snps are not considered to be part of this specific body of literature inasmuch as they explore the reproduction of power structures in online environments and their impact on news media and communication at large these contributions discuss online propaganda as a byproduct of such dynamics rather than directly addressing its function and role as a political practice for this reason they are not addressed in this paper as they exceed the scope of this analysis frontiers in sociology frontiersinorg aims encompassing social controlin the case of authoritarian statesissuesalience alterations and framing for electoral goalsin democratic regimes in terms of organizational structure these actors also vary greatly with investigations showing significant differences in terms of capacity coordination and resources the supplyside literature on online propaganda has also provided important insights into the treatments and settings dimensions of the phenomenon by exploring production and dissemination strategies employed by propagandists on snps by mapping propaganda networks as well as the type of messages circulating through them researchers have developed a detailed depiction of the online ecosystems where this kind of material proliferates identifying diffusion patterns as well as techniques adopted for maximizing message propagation on this latter they have uncovered the widespread use of automation to enhance the circulation of specific political stances as documented in numerous studies on political bots it is interesting to notice that automation in addition to enhancing dissemination also serves the purpose to maintain propagandists anonymous throughout the communication processa crucial aspect in ensuring that also their intentions remain concealed despite a preponderant focus on speakers settings and treatments the supplyside strand also includes contributions that have tried to address the outcome dimension of the phenomenon however these studies remain speculative in nature as authors never empirically assess their postulations on online propaganda effectswhich they identify as the manipulation of public opinion in fact they do develop some theoretical considerations regarding the macroprocesses through which the manipulative power of online propaganda unfolds but such considerations account only for the alteration of the political narratives on snps failing to explain how the alteration translates into the manipulation of public opinion authors do recognize this issue attributing its causes to the difficulty of empirically establishing causal claims on effects that transcend the online realm however i would argue that as in the famous case of the macedonian teenagers who created and disseminated protrump material for profit in defined as user account s that ha ve been equipped with the features or software to automate interaction with other user accounts about politics building on the agendasetting theory mccombs and shaw mccombs et al these authors claim that the systematic use of computational tools allows political actors to bypass traditional gatekeepers of information and directly alter the salience of specific topics in the online public discourse in this way they drive media coverage toward political issues and narratives considered more advantageous for their faction thereby shaping the political debate and influencing the electorate the problem is first and foremost theoretical and that the empirical challenges identified by these authors are a consequence of it as a type of communication online propaganda involves the interaction between two actors speakers and receivers it is in the unfolding of this interactionand not in the actions of one or the other actor alonethat the mechanisms determining the persuasive result should be sought it follows that if receivers and their response to online propaganda are systematically neglected in the postulation of such mechanisms the assessment of the persuasive outcome becomes virtually impossible therefore to go beyond postulations that seem to simply assume an automatic link between exposition to propaganda material and a voluntary change of attitudes andor behavior direct engagement with propaganda recipients must be envisaged when discussing online propaganda outcomes the demandside approach exploring online propaganda e ects on its targets scholars adopting a demandside approach to the study of online propaganda are interested in exploring the effects this communication practice generates in its targeted audience as such their investigations tend to focus on the persuasion process triggered by these political messages with the aim to identify the micromechanisms underpinning evaluations and behavior of those exposed to them given these research objectives contributions belonging to this strand of the literature touch on all four dimensions of the gp framework albeit focusing on only some of the components that fall under these dimensions indeed the demandside scholarship is interested in assessing online propaganda outcomes by identifying factors that influence themnamely settings treatments and characteristics of receiverand explaining their underlying mechanismsie the process through which information is assessed and decisions are formed conversely from their supplyside colleagues demandside scholars are not interested in investigating how social media users end up getting exposed to online propaganda but they are rather concerned with the cognitive mechanisms that are activated once exposure has occurred it follows that their primary focus is receivers and the way they process and respond to online propaganda therefore the outcomes they are interested woolley and howard indeed maintain that making a causal claim from social media use to citizen engagement trust in institutions or voter sophistication is proving di cult to do even in countries for which there are significant amounts of data some contributions belonging to the supplyside strand have provided interesting insights into the type of users who are more likely to be exposed to and engage with online propaganda on snps by exploring the characteristics and the behavior of their social media accounts however such information is mostly descriptive as it is based on online available data that as such does not explore the decisionmaking process underlying the displayed behavior frontiers in sociology frontiersinorg in are those related specifically to these actors that is the observable voluntary changes in the attitudes and behaviors of the recipients as previously discussed it is extremely complex to causally link exposure to online propaganda with offline behavior as the effects of online political persuasive content on electoral outcomes or other behavior have yet to be reliably detected therefore the outcomes studied usually concern receivers evaluation of online propaganda material and the response such material elicit on the one hand this means assessing users perceptions of information credibility reliability and accuracy on the other hand it means investigating online engagementwhich is usually operationalized as sharing behaviorprompted by propaganda content to understand whether and how these evaluations and behaviors are altered by online propaganda researchers have identified and investigated the influence exerted by three main factors the design of online propaganda messages the features of the information environments in which these messages are circulated and processed and the characteristics of those exposed to such messages studies addressing the first factor investigate how different message features that are commonly employed to evaluate information validity and saliencesuch as source endorsement emotional salience popularity stereotypes and topic are purposefully manipulated and used by online propagandists to alter the attitudes and behaviors of their targeted audience investigations focusing on the second factor explore how the very design of snps affects the way information is accessed processed and finally evaluated indeed such environments are characterized by an overabundance of informational stimuli constantly competing for users attentiona condition that impairs the ability to process and evaluate information analytically and that as such can be exploited by online propagandists to enhance the circulation of their messages finally when exploring the role recipients characteristics have in affecting online propaganda persuasive outcome demandside scholars tend to concentrate on those aspects that are in direct relation to the piece of information evaluated namely receivers intended as the extent to which there are reasonable grounds for believing information conveyed understood as the quality of being trustable because of previous experience indicating so intended as the ability of informationproviders to convey correct information prior attitudes and evaluative beliefs toward the issue addressed by propaganda messages as well as the motivation and effort these actors put into processing the information they are exposed to to provide compelling explanations on how these factors affect the evaluation process of online propaganda material and determine a voluntary change of attitudes andor behavior in the targeted audience researchers often resort to the concept of heuristic reasoning this draws from the dual process models of cognitiona theory that envisages the existence of two distinct but interdependent systems that regulate the thinking process despite the ongoing debate on the specific characteristics and relations between these two systems scholars agree on their basic functioning one system is intuitive and does not require controlled attention during information processing while the other is deliberate and necessitates more cognitive resources to perform mental tasks because of its speed and cognitiveenergy demands the former system is often employed in situations where reasoning capacity is impairedsuch as in the case of high informational load or in cases of high uncertaintywhen fast solutions are preferred though satisfactory for reaching immediate goals this system is subject to systematic bias as it relies on the uncritical application of preexisting knowledge structures rather than an indepth analysis of the information received therefore the reliance on this system when processing information can lead to flawed evaluations and behavior given its premises the dual process modeland in particular the concept of heuristic processinghas been largely employed by demandside scholars to theoretically postulate and then empirically explore the cognitive mechanisms underpinning the assessment of online propaganda regardless of the specific factor or outcome investigated empirical discoveries offered by this strand of the literature indicate that heuristic reasoning plays an important role in the persuasion process prompted by online propaganda though compelling these results are affected by some important limitations that mostly concern the way these cognitive mechanisms are conceived and consequently assessed overall studies building on the dual process model framework tend to have a universal approach to cognition meaning that they conceive cognitive processes as common procedures shared by all individuals regardless of their socioeconomic cultural ethnic or political background however such factors have been demonstrated to play an important role in shaping these processes as they make cognitive referents more accessible or prominent than others during information assessment and decisionmaking neglecting these elements could limit result interpretation and thus potentially hinder the overall understanding of the mechanisms underlying complex social phenomenaespecially if they involve communication practices as in the case of online propaganda indeed numerous studies have highlighted how communication is affected by sociocultural factors that do not only influence the way a message is processed and evaluated but also how that very message is designed and conveyed notwithstanding such arguments demandside investigations of online propaganda impact tend to neglect sociocultural differences in both treatment design and effect assessment engaging with sociocultural factors would therefore help this strand of the literature to relax the homogeneity assumptions that currently characterize its investigationsas these are rarely justifiable when compared to realworld scenarios characterized by high intrinsic diversity both in terms of propaganda material and recipients characteristics discussion bridging online propaganda literature employing the gp framework as a common frame of reference to analyze the disconnected body of literature on online propaganda offers a dual advantage firstly it facilitates the identification of variations among different strands of the literature in terms of the specific dimensions and components addressed thus supporting the development of a structured overview of the stateoftheart secondly it enables the placement of gaps and limitations of each strand within these dimensions and components in this sense the adoption of a common framework proves beneficial not only in clearly identifying the shortcomings of both supplyand demandside strands but also in exploring avenues to bridge such strands indeed this systematization has highlighted how this bridging process can be streamlined on the one hand by comprehending how the identified differences can be translated into valuable insights that each strand can employ to overcome its limitations on the other hand by exploring how the contributions offered by other research programs that focus on the interaction between cognitive and sociocultural factors can provide additional support to address such shortcomings this integration of diverse perspectives would reduce fragmentation by harmonizing currently disjointed theoretical conceptualizations and empirical findings moreover it would advance the research agenda on online propaganda by explicitly considering the interplay between its cognitive and social components getting the dialogue going how each strand of literature on online propaganda can contribute to the development of the other engaging in a constructive dialogue between the supplyside and demandside strands of online propaganda literature can be advantageous for both as each strand has the potential to offer valuable research tools to the other aiding in the resolution of certain limitations that impact their respective areas as previously discussed the supplyside strand is preoccupied with the sociopolitical factors leading to the emergence and endurance of online propaganda to this aim it focuses its investigations on the political actors involved in the production and dissemination of such political content and the strategies they employ to amplify its circulation notwithstanding its compelling findings this strand remains primarily descriptive with a disproportioned focus on the speakers component and some untested assumptions on the persuasive outcomes this type of communication generates to better understand the persuasive power of online propaganda and its resulting effects it is essential for this strand to consider the receivers component and the cognitive mechanisms that underpin their information processing and evaluation this does not imply replicating or fully incorporating the research conducted by the demandside strand but rather acknowledging its existence and drawing from it when discussing online propaganda outcomes by doing so these contributions can be better positioned within the existing literature and in relation to the demandside strand additionally this would also enable a reevaluation of the social harm associated with online propaganda as some have raised concerns about the validity of claims based solely on computationally intensive methods applied to social media data without reference to realworld populations conversely the demandside strand delves into the persuasion processes triggered by online propaganda assessing its impact on users evaluations and behavior as such it investigates how individuals process and respond to these persuasive stimuli to identify the cognitive mechanisms underlying such reactions though rich in insightful findings on the outcomes produced by this kind of communication this account as well is affected by some important limitations by primarily focusing on the recipients component investigations belonging to the demandside strand tend to systematically overlook the sociopolitical context in which propaganda is created and disseminated when assessing its impact on the targeted audience furthermore such assessments often adopt a universalistic perspective on cognition assuming that cognitive processes underlying the evaluation of political content are universally applicablean assumption that completely neglects the impact sociocultural factors have on cognition and thus on the evaluation of online propaganda content however drawing from the insights offered by the supplyside strand could help to partially mitigate such shortcomings and achieve a better interpretation of experimental results the descriptive findings provided by the supplyside literature regarding on the one hand the actors involved in online propaganda production and on the other hand the consumption and diffusion patterns of propaganda on snps can help contextualize the effects of exposure to online propaganda indeed by drawing from these contributions it would be possible to delve into the specificities of the sociopolitical context in which online propaganda is produced and disseminated facilitating the development of more consistent stimuli tailored to specific subpopulations under investigation moreover knowledge of the circulation and consumption patterns of online propaganda can be extremely useful for verifying the intuitions guiding the experimental assessment of the effect this communication practice has on users judgments and behavior as these realworld observations can be used as ground rules to compare experimental findings with overall considering how each strand of the literature can build on the other to overcome its limitations is the first important step toward bridging online propaganda literature however this would still not be sufficient to address all the shortcomings affecting both strands particularly those related to the neglect of sociocultural factors when investigating the functioning and outcomes of online propaganda as previously mentioned these factors profoundly affect human communication practices including the way people process and evaluate messages therefore they should be acknowledged when investigating online propaganda as they can help interpret and contextualize findings and provide a more comprehensive understanding of the underlying mechanisms that produce them how cultural and cognitive sociology can further bridge and enhance online propaganda scholarship to address these remaining shortcomings i argue that drawing from sociologyin particular from its cultural and cognitive brancheswould be beneficial as this literature provides important insights and research tools to disentangle and evaluate the role played by supraindividual factors in the production distribution consumption and evaluation of online propaganda indeed utilizing the contributions provided by this scholarship would help in better contextualizing the settings in which online propaganda is produced and supplied as well as advancing the understanding of the mechanisms underlying online propaganda outcomes by exploring and comparing the role that history language cultural system and social differentiation play in the production and distribution of online propaganda across different contexts it would be possible to evaluate how these factors influence and differentiate online propaganda dynamics this contextualization could potentially aid the interpretation of existing findings that show significant variations in terms of speakers involved and persuasion strategies employed across settings since salience credibility and effectiveness of certain political actors or messages are likely to depend on the sociocultural specificities characterizing the society in which this form of communication takes place furthermore an improved understanding of the outcomes and underlying mechanisms of online propaganda can be achieved by examining how sociocultural factors interact with cognition and mutually shape each other thereby influencing the evaluation of online propaganda messages contributions from cognitive and cultural sociology have indeed demonstrated that the cognitive mechanisms involved in information processing and decisionmaking are not universally applicable as they are influenced by cultural repertoiresnamely the available schemas frames narratives scripts and boundaries that actors draw on in social situations these repertoires are distributed unevenly among individuals who share the same national membership due to their transmission and diffusion by specific intermediariessuch as religious leaders political parties and media outletswhich may vary in prominence across different social groups social differentiation thus plays a crucial role in determining the accessibility of cultural repertoires to different groups as differently structured social environments enable certain cultural references to be more readily available to some individuals than others consequently this has an impact on how messages are processed interpreted and evaluateda crucial insight that should be taken into account by scholars who are interested in identifying the different components underpinning the evaluation of online propaganda therefore engaging with sociocultural factors when investigating the functioning and outcomes of online propaganda would have the dual advantage of helping overcome the limitations affecting both research strands and further bridging the overall literature on online propaganda by considering sociocultural factors researchers can move beyond a descriptiveand often anglocentricunderstanding of online propaganda production and distribution reaching more comprehensive conclusions regarding the prominence and significance of specific platforms actors and diffusion patterns across different national and subnational context supplyside scholars can therefore enhance their findings by incorporating these factors into their investigations thus also responding to recent calls numerous researchers have made to ground online propaganda studies in history society culture and politics to avoid neglecting the role race ethnicity language colonial legacy gender and class have in this phenomenon to do so new theoretical and empirical analyses should focus on how social differentiation influences the dynamics of persuasive communication for instance when examining consumption and diffusion patterns of online propaganda on snps researchers could explore whether the most prominent accounts in these networks exhibit specific characteristics that symbolize their belonging to a trusted and authoritative group within the sociocultural context similarly they could expand upon insights from political bot research by investigating whether the display of culturalspecific traits and codes such as jargon religious symbols or impersonation of community members aids automated accounts in spreading propaganda content on social networking platforms and building trust among their targeted audience acknowledging the influence of sociocultural factors would also enable researchers to move beyond a universal and static perspective of the cognitive mechanisms involved in the evaluation of online propaganda by recognizing that cultural repertoires shape cognition and that their distribution varies among diverse social groups demandside scholars can achieve a more comprehensive understanding of how sociocultural factors shape cognitive processes and subsequently impact attitudinal and behavioral outcomes produced by this form of communication indeed including sociocultural factors in the formulation and evaluation of the mechanisms underpinning online propaganda effects would allow researchers to relax the homogeneity assumption previously discussed and provide stronger causal explanations for the variations observed among recipients in terms of their response to online propaganda to achieve such an objective researcher could for example collect sociocultural information along with the more classical demographics during experimental assessments of online propagandas impact on users evaluations and behavior this would allow for the estimation of heterogeneous treatment effects to assess whether individuals with similar sociocultural backgrounds exhibit consistent responses to specific propaganda stimuli by employing this approach it would be possible to gain a deeper understanding of whether susceptibility to online propaganda persuasion strategies is influenced by supraindividual characteristics this would provide scholars with new lens through which to explore and analyze patterns of vulnerability thus further developing our understanding of online propaganda impact on individuals the acknowledgment and inclusion of sociocultural factors when investigating online propaganda functioning would further bridge the supplyand demandside strands of literature indeed adopting a consistent research approach that incorporates sociocultural factors in both conceptualizations and empirical assessments would facilitate the dialogue between the two strands fostering meaningful knowledge exchange about this type of communication moreover adopting a sociocultural approach would serve as a cautionary measure against generalizedand sometimes oversimplifiedpolicy proposals aimed at countering online propaganda whether these proposals target the persuasive influence of propaganda or seek to regulate its dissemination i argue that considering the sociocultural specificity of different target audiences is crucial for instance scholars developing debiasing treatments that target cognition would benefit from the inclusion of sociocultural factors in their analyses as this would allow them to develop more effective debiasing stimuli that account for the diversity characterizing online propaganda audience indeed by taking into account that individuals sociocultural background affects the availability of cultural repertoires and thus the cognitive mechanisms underlying informationprocessing and decisionmaking researchers would be able to design tailored debiasing treatments that work best for specific sociocultural groups similarly regulations that prescribe content and behavior limitations on snps and envisage social media companies for an overview of governance responses in the european system see saurwein and spencersmith responsibilities in implementing such restrainsshould be designed by considering how sociocultural factors interact with the production and consumption of online propaganda on the one hand this means acknowledging the specific use that political actors and citizens make of these platforms in different contexts by identifying and assessing for example the most prominent platforms for political communication the extent to which automation is employed the type of actors involved in dubious communication activities and the characteristics of diffusion and consumption patterns on the other hand it means considering the broader characteristics of the online media ecosystem including how its ownership structure and the power dynamics that emerge from its interaction with the offline social world influence the production and consumption of such political content overall integrating the demandand supplyside strands of research on online propaganda would enhance our knowledge of how propaganda impacts individuals cognitive processes and behavior within specific sociopolitical contexts by incorporating insights from both perspectives researchers can conduct more rigorous and comprehensive analyses making valuable contributions to the field moreover by drawing on the insights offered by cultural and cognitive sociology an improved understanding of the outcomes and underlying mechanisms of online propaganda can be achieved embracing a cultural perspective in the study of online propaganda would contribute to a more holistic understanding of this communication phenomenon indeed it would allow scholars to explore factors that account for significant variations among diverse social groups which often stem from existing patterns of inequality that result in uneven distributions of material and cultural resources 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

overcome the fragmentation in online propaganda literature the role of cultural and cognitive sociology

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introduction the field of social entrepreneurship is growing rapidly but enthusiasm has outpaced conceptual development and refinement and controversy on the meaning of se persists while previous conceptualization and operationalization studies undeniably provide valuable contributions to advance knowledge in this bolstering academic field the adopted classical conceptual structure based on necessary and sufficient attributes fails to capture se as an essentially contested concept often led by advocacy worldviews of the researchers themselves scholars tend to either treat discrete features of se as equivalent to the broader concept or use a rigid monothetic conceptual structure based on a single basic principle that potentially excludes some actors who may also identify themselves with se the plethora of se definitions has not only been related to differences in how attributes are combined to define se but also associated with distinct ethical views and normative conceptions of se concept formation lies at the heart of all social science endeavors not only because it addresses the fundamental question of what we are talking about but also because in doing so it allows for knowledge to accumulate and progress conceptual confusion and persistent disparity in terminology create serious obstacles to accumulate knowledge because what is presented under the banner of se is different from one publication to another setting an urgent call to systematize the scattered knowledge developed so far following an organized set of activities that set priorities for what needs to be done in order to develop a strong conceptual definition our study aims to advance the discussion on conceptualizing se by answering three research questions which attributes identify se how are the attributes organized in existing academic conceptualizations and how do different sets of attributes relate to distinct ethical views based on an extensive sample of 209 academic definitions of se and their supporting academic articles we identify 12 attributes that comprehensively define the se concept reveal the existing multitude of attribute combinations and shed light on the distinct ethical views that cooccur with specific choices of attributes previous studies have already investigated different definitions of se to conclude that either it is an essentially contested concept that cannot be defined beyond a set of clusters of other overlapping concepts or a classical one holding a specific set of necessary and sufficient attributes and implicitly excluding divergent perspectives of se toward a more inclusive model this study refutes both the undefinable nature of se and the classical structure of concept definition rather we propose that se follows a family resemblance conceptual structure in which membership is not defined by a case possessing a universally accepted set of criterial features but by carrying shared attributes with other cases there are important implications for se research in acknowledging the family resemblance structure we untangle the fallacy of assuming that different phenomena are the same just because they carry the same se label and caution against causal homogeneity assumptions among distinct se subtypes that result from different combinations of attributes furthermore our results contribute to set a sound path to operationalize se because differences in definitions lead to differences in measurement by clearly identifying the attributes of se this study supports the design of rigorous measurement instruments to empirically capture the different attributes and to investigate theoretically relevant causal relationships finally this study also contributes to the ongoing reflection on the normative ethical foundations of se and argues for the merits of looking at those foundations from a descriptive approach theory conceptualizing social entrepreneurship a considerable number of conceptual studies on se emerged at the beginning of the century stressing different aspects of the phenomenon and reaching a peak around 2006 when several highly cited papers were published following the abundance of publications in the academic field scholars presented several excellent reviews some of which focus specifically on ses conceptual definition while some of these reviews provide a unique definition of se others conclude that a universally accepted definition of social entrepreneurship is hardly possible arguing that a cluster concept would enable systematic future research on se the same authors recognize that these overlapping clusters are also contested complicating the applicability of the cluster concept as conceptualization articles tapered off operationalization efforts began to emerge building on different definitions and attributes of se lepoutre et al measure social entrepreneurial activity based on individuals selfreported social mission innovation and marketbased revenues stevens and colleagues define se as entrepreneurship with an embedded social purpose which is sustainable through trade and not limited to a particular organizational form developing a scale to measure the social and economic missions of a social enterprise kannampuzha and hockerts suggest that organizational social entrepreneurship is a formative construct based on three componentssocial change intentions commercial activities and inclusive governance within the nonprofit sector morris et al suggested adapting the entrepreneurial orientation construct to the nonprofit context the social entrepreneurship orientation scale has four dimensions according to kraus et al and five attributes in dwivedi and weerawardenas study the use of divergent sets of attributes reflects the enduring lack of consensus most of these efforts use a classical approach to conceptualize se claiming a universal set of singly necessary and jointly sufficient attributes clashing with previous arguments for its contested nature recognizing the valuable contribution of these studies in refining the se construct the pursuit of operational definitions without acknowledging a broader frame of the concept risks legitimizing powerful actors in the field rather than capturing the existing diversity of perspectives we share other scholars concerns that in the quest to find a consensual definition perspectives defended by less powerful actors might become marginalized and agree that over time this imbalance might be expected to undermine and perhaps even destroy the normative and cognitive legitimacy of social entrepreneurship to a wider audience relating ethical theories and the concept of se scholars relate the existing diversity of se definitions with distinct ethical views and normative conceptions of se while a few studies may acknowledge the diversity of perspectives in se and different philosophical lenses underlying the concept most studies tend to assume a normative posture toward se for example bruder describes utilitarian tendencies and economistic confusions in a vast number of se conceptions and proposes an integrative economic ethics based on kantian deontological theory to ground the se concept as good entrepreneurship bhatt suggests that social enterprises are marketbased hybrid organizations with a dual mission of financial sustainability and social value creation and seem to exclude other organizational formats from se normative ethical theories are generally presented in three broad branches consequentialism deontology and virtue ethics in consequentialism the moral worth of actions is determined by their consequences the most familiar form of consequentialism is classical hedonistic act utilitarianism which claims that an agent ought to perform that action that produces the most net pleasure for everyone concerned an essential feature of utilitarianism is the principle of optimal productivity through efficiency in rule utilitarianism moral behavior requires adopting rules based on the consequences they may have finally economism is based on the maximization of selfinterest as the rational mechanism to promote economic welfare deontological ethics postulates that the morality of an action is based on whether that action itself is right or wrong rather than based on its consequences within deontology kantianism argues that actions must satisfy the categorical imperative of human dignity claiming that a person should be treated as an end and never purely as a means to the end of others informed by kantian theory habermasian discourse ethics is a process oriented ethical perspective that emphasizes the participation of all affected parties in fair dialogues to establish moral norms moral rights theory is a current deontological ethical view which grounds ethical theory in an account of personal claims and enforceable duties that render other persons liable which are not reducible to a theory of obligations or virtues distinct from the previous ethics of conduct virtue ethics does not rely on a mechanical algorithm based on the consequences or on the acts themselves for making the right decision based on an ethics of character virtue ethics views moralitys primary function to cultivate virtuous characters with the disposition to do the right thing for the right reason in an appropriate way extending previous ethical reflections on se our study focuses on ethics to understand persistent conceptual controversies that still prevail in defining se in this paper we depart from previous normative viewpoints and take a descriptive stance to portray how distinct ethical views relate to different conceptions of se family resemblance versus classical conceptual structures the family resemblance structure is an alternative to the classical conceptualization approach and defines complex concepts for which no single set of characteristics is common to all variants a family resemblance relationship consists of a set of items of the form ab bc cd de that is each item has at least one and probably several elements in common with one or more other items but no or few elements are common to all items the concept of games and the common attributes in its subsets board games card games ball games and olympic games represents an example of a complicated network of similarities overlapping and crisscrossing among the subsets concepts holding a family resemblance structure are not bounded entities in which membership is defined by an item or case possessing a simple set of criterial features rather cases that share many attributes with other cases bear greater family resemblance and are more ideally representative of the concept than members sharing only a few attributes every attribute must be shared by more than one case from the same conceptual space and those attributes shared by many cases are more central than others shared by only a few cases the explicit application of the family resemblance structure has been scarce in the management literature with a few notable exceptions such as practice theory and privacy there are important implications from assuming the family resemblance as the underlying structure of a concept first unlike classical concepts family resemblance ones accommodate members possessing different sets of attributes the or rather than the and structural logic that underlies the family resemblance structure allows for membership arguments stressing differing features aggregating distinct perspectives on the concept under the same conceptual space without ignoring existing variance additionally conceptual subtypes in a classical structure capture variation by adding an extra and nonessential attribute to the original concept in contrast to form subtypes using a family resemblance structure barrenechea and castillo propose a method of grouping the existing attributes used in defining the concept and recommend turning to the subtypes to gain the differentiation that is lost by the inherent nature of these structures finally one of the defining features of the family resemblance structure is attribute substitutability which hampers causal homogeneity that characterizes classical concepts implying that antecedents and consequents may not be the same across conceptual subtypes following literatures guidelines to develop good conceptual definitions our study allows for the conceptual structure to emerge from the data in the next section we describe the research methods employed then we present and discuss our findings finally we acknowledge the limitations of this study and summarize our main contributions methods overall research design to answer our research questionswhich attributes identify se how are they organized and how are they related to distinct ethical viewswe designed and guided our research based on the stages for strong conceptual development recommended by podsakoff et al identify potential attributes of the concept by collecting a representative set of definitions organize the potential attributes by theme and identify any necessary and sufficient or shared ones emphasis added develop a preliminary definition of the concept and refine the conceptual definition we started by collecting a representative sample of 209 definitions of se because in those cases where several different conceptual definitions already exist then conducting a thorough review of the literature identifying the key attributes based on these definitions and organizing these attributes into meaningful conceptual themes before developing their definition may be the most important activities then we analyzed the content of the definitions to identify the potential attributes of se generating tentative categories or themes from asking the specific question which themes do scholars use in defining se and refining them until we distilled 12 attributes next we looked for patterns in how the themes were organized across different definitions finally realizing that se definitions organized attributes in a variety of distinct combinations we reviewed the corresponding articles to understand how divergent ethical stances relate with the plethora of se conceptualizations data collection we collected our sample of definitions in three different periods to ensure geographical and temporal representativeness first through snowball sampling and starting with definitions identified by santos we found dacin et als list of 37 definitions and to zahra et als list of 20 definitions adding their own definitions in these works we found two additional lists massetis with 11 definitions and weerawardena and morts with 20 this initial sample of 60 unique definitions covered the period in which most conceptualization studies were published and contained highly cited definitions however this list included definitions prior to 2012 and was potentially biased toward american perspectives to circumvent these limitations we considered two additional sets of se definitions alegre et al systematically reviewed 307 articles until april 2015 from which we added 94 nonoverlapping definitions to our sample subsequently we conducted a systematic review of articles from 2015 to september 2018 searching titles abstracts and keywords for the expressions social entrepreneurship social enterprise and social entrepreneur we included articles from top journals important to se research selected by short et al and those identified by alegre et al collecting 107 additional articles not surprisingly most scholars in this last period used earlier conceptualizations as working definitions after adding 55 new definitions our final sample comprised 209 unique definitions of se data analysis our data analysis evolved in three different stages mostly based on going through qualitative data to generate categories that would answer our research questions to explain the analysis conducted we build on the analytical moves identified by grodal et al because researchers can demonstrate rigor by detailing more precisely how they have purposefully drawn on a broad and diverse set of moves to engage with their data in a first stage we investigated both the 209 definitions and respective articles to identify and distill the attributes of the se concept we started analyzing the content of the 209 definitions by asking questions the move in which researchers draw on their existing categories to select and approach data with specific questions to which they would like to answer the authors explain that asking questions is a core part of early discovery because it enables the creation of initial categories for the problem at hand specifically we started looking for categories in our sample by asking the question which themes do scholars use in defining se from our sample of 209 definitions we extracted 651 expressions by breaking up each definition in different themes for example bornsteins definition was separated in five different expressions that relate to different themes a social entrepreneur is a pathbreaker with a powerful new idea who combines visionary and real world problem solving creativity who has a strong ethical fiber and and who is totally possessed by his or her vision for change being aware that not all information is equally important in the categorization process we were nevertheless careful to analyze and code all the words as stated in each academic definition because each definition already synthesizes each scholars perspective on the key attributes of the concept as such leaving out parts of the text could lead to missing out less salient attributes then to reduce data we merged categories by uniting expressions to create superordinate categories based on similarities and differences among the expressions extracted for example we merged expressions such as with a powerful new idea who combines visionary and real world problem solving creativity with new ways pioneers of innovation new programs services and solutions into a superordinate category we labeled innovativeness through this merging process we progressed from lower to more complex categories significantly reducing the number of expressions to 15 tentative categories of which 14 themes referred to potential attributes of se and one category related to the unit of analysis next to distill se attributes from the tentative categories we read and analyzed the articles from which the definitions were extracted to understand what academics mean in each theme they draw on to define se using nvivo to aid in the qualitative analysis of the articles we started coding them not only using the tentative categories that emerged from the previous step as the initial codes but also adding new categories to code data that could bring additional definitional clarity to the se concept for example we also coded how academics define conceptual boundaries between se and related constructs such as csr business or commercial entrepreneurship social activism and traditional nonprofits the codes referring to tentative categories of attributes were further expanded as different meanings were identified for an initial category for example employing the qualitative move splitting categories we separated the sustainability category into two different codes related to sustainability of the impact and selfsustaining activities which was then merged with the code commercial activities refinement of tentative categories also involved relating and contrasting categories for example we identified that innovativeness proactiveness and risktaking were related to the entrepreneurial behavior category as these categories are often mentioned together in academic papers we also related the category commercial activity with entrepreneurial behavior after contrasting the distinct meanings of the latter category based on the articles we shed light on the different meanings assigned to each attribute highlighting conceptual controversies we identified these controversies either from explicit references to different schools of thought explicitly identify different schools of thought regarding se attributes or implicitly from the existence of different academic perspectives on a certain attribute conceptualization paper versus profit distribution in battilana et als paper we concluded this first analytical stage by distilling from the initial 14 themes the 12 attributes that exhaustively cover the definitions analyzed in the second stage podsakoff et al suggest investigating how attributes are organized among definitions using the initial 14 attributerelated themes we saw them as distinct building blocks that scholars pick and choose to combine and provide their own definition of se we mapped all combinations of themes by creating a table in excel with each definition in a row and each of the 14 themes in a column for each row themes were identified as present with 1 and missing with 0 after concatenating the results of each row we counted the frequency each combination appeared in our sample of 209 definitions despite the diversity of existing combinations we analyzed the patterns of attribute association to identify the prominent se conceptual subtypes to that end we counted the frequency of each pair of attributes appeared simultaneously in se definitions we also investigated how the 14 themes related to different units of analysis to that end we classified and grouped the different expressions referring to units of analysis in five levels individual organization process context and other in the final stage podsakoff et al suggest refining and providing a tentative definition for the concept building on previous research relating se conceptualizations and ethical stances we propose refining the se concept through clarifying relationships with ethical views explicitly or implicitly stated in academic papers to do so we went back to the analysis of the academic papers using the three broad branches of normative ethical theory as templates we reviewed the data previously coded in tentative categories associated with se attributes and recoded them according to ethical positions explicitly stated in the articles associated with the choice of attributes and their meanings in this process we split the three broad categories in more specific ethical views for example we split the category consequentialism in act utilitarian rule utilitarian and economism whenever the explanation or relevance of an attribute was not clear we reread the papers in search for additional arguments that would identify the scholars position in the next section we report the results of our analysis results stage i identification of attributes the content analysis of the 209 definitions of se is summarized in table 1 we identified 14 initial themes used in characterizing se in academic definitions and an additional category related to the unit of analysis for clarity purposes we grouped the 14 themes in three main elements of the se concept the social element which includes social goals transformational change sustainability of the impact and virtuosity the entrepreneurial element which relates to innovativeness entrepreneurial behavior proactiveness commercial activity resourcefulness and willingness to take risk and the managerial element which includes profit reinvestment businesslike approach scalability and collective governance next we provide an account of what scholars understand of each of these themes themes related to the social element we identified four different themes that academics refer to in defining the social element of se first most scholars agree that having a social mission addressing social problems or creating social value is a key attribute of se conceptions of se often state that the mission needs to be social but do not spell out exactly what a social mission is what constitutes social goals is still controversial some scholars specify social goals by normatively enumerating them seelos and mair propose the widely accepted united nations millennium development goals as the ultimate goal of se in the same vein kroeger and weber argue that the goal of social interventions is to create positive changes in the life satisfaction of individuals disadvantaged in a specific life domain other academics define social goals as opposed to economic ones arguing that se creates social value while commercial entrepreneurship creates value for personal or shareholders wealth drawing on economic theory santos counterargues that a clear dichotomy between social and economic value is complicated because economic goals are inherently social as they improve social welfare through a better allocation of resources in addition to the lack of consensus defining what social goals are scholars also discuss the centrality of the social mission visàvis economic goals or other legitimate aspects extraneous to profitability and mission success the second theme related to a social element that emerged from our sample was transformational change cited in 38 definitions some se definitions refer to the importance of having a social objective or social purpose without explicitly referring the se actor as a change agent in this view any kind of social goal is sufficient to identify se phenomena and t here is no exact way of fixing the border below which the importance of social goals fails to qualify something as social entrepreneurship other authors argue that more than alleviating social needs the social mission should seek to change the status quo achieving a new equilibrium that will solve a social problem implying structural shifts that transform behavior and promote systemic social change thirdly in defining se sustainability refers either to the organizations ability to selffinance its activities a topic we address ahead together with other entrepreneurial related themes or to the sustainability of social impact and the provision of lasting social benefits regarding this latter meaning related to social goals the aim to provide lasting benefits is sometimes seen as a distinctive feature of se more than a quick hit social entrepreneurs are concerned with sustaining their impact by creating lasting improvements which requires developing a solution that eventually eliminates the problem permanently in this sense sustainability of the impact overlaps with the previous discussion on transformational change and is not an additional attribute of se finally still related to the social element of se a few scholars cite virtuosity as an attribute of se because it focuses on solving social problems rather than pursuing a profit or donating profits to a cause others argue that there is considerable need to research further the ethical context of social entrepreneurship and enterprise santos posits that social entrepreneurs do not need to be defined as good or moral agents that want to help others but rather as economic agents who due to their motivation to create value without concern for the amount they capture will enter areas of activity where the more severe market and government failures occur opposing to this claim bruder states that the prefix social carries the normative validity claim of being good entrepreneurship proposing that a utilitarian view of overemphasizing either a social mission or economic goals may lead to unethical practices themes related to the entrepreneurial element the analysis of the 209 se definitions also evidenced six themes associated to an entrepreneurial element of the se concept the manifestation of entrepreneurial qualities behaviors or strategies is a core theme defining se however the meaning of entrepreneurship varies among different people in a minimalist sense it might refer to starting a business based on commercial activity or in a popular sense borrowing business methods or even from its french origin accepting a challenging task which involves innovativeness resourcefulness proactiveness and risktaking to avoid tautology and confusion we disaggregate the discussion on the entrepreneurial behavior theme in its specific meanings first referring to entrepreneurships french origin we examine the themes related to innovativeness resourcefulness proactiveness and willingness to take risk then in line with a minimalist sense we debate the theme commercial activity and the concern with organizational selfsustaining strategies finally we discuss the popular interpretation of entrepreneurshipbusinesslike approachin the next section together with other managerial related themes starting with innovativeness scholars repeatedly use terms such as new programs new services new solutions new activities new ideas or new combinations of resources to characterize se innovativeness or the quality of introducing new ideas reflects an important means by which new opportunities are pursued innovativeness in se does not necessarily mean creating a new product or service and is often associated with developing new models approaches methods of production strategies and ways of organizing in order to increase effectiveness and efficiency in tackling a social problem akin to the innovativeness theme resourcefulness is a topic cited in 28 se definitions unlike their business counterparts social entrepreneurs leverage whatever resources available regardless of norms or conventions that usually limit more traditional sectors profitseeking firms typically mobilize resources that are valuable rare inimitable and nonsubstitutable which they seek to deny to competitors to obtain a competitive advantage social entrepreneurs in contrast often leverage abundant resources outside the organizations boundaries using them collaboratively with other players next proactiveness means taking the initiative by anticipating and pursuing new opportunities scholars often mention proactiveness as a core attribute of se referring to the direct action involved in pursuing an opportunity earlier definitions viewed the social entrepreneur closer to a social activist playing critical roles in bringing about catalytic changes in the public sector agenda and in the perception of certain social issues more recently scholars argue that se differs from social activism as it requires the creation of an organizational context and direct action in solving a social problem an se opportunity differs substantially from a commercial opportunity because the former is more prevalent and urgent enables more accessibility and collaboration and might require especially innovative approaches then willingness to take risk is a theme mentioned in only nine se definitions tan and colleagues explain that willingness to take risk is a necessary but not sufficient condition of any entrepreneur however other academics note that rather than willingness social entrepreneurs exhibit tolerance to risk and appear to adopt a highly cautious approach in dealing with risk and rather than risk social entrepreneurs face ambiguous scenarios and probabilities in which nascent markets and unknown structures complicate the ability to predict revenue streams finally cited in 41 percent of the se definitions analyzed commercial activity is also an entrepreneurship related theme viewing entrepreneurship as starting a business with a commercial activity some scholars argue that earnedincome strategies to selfsustain the organizations activities and the simultaneous pursuit of social and economic goals are fundamental attributes of se despite the increasing inclination in se toward structures that combine conflicting elements for other scholars social enterprises defined as organizations whose goal is to achieve a social mission through commercial activities are not the only type of organizations pursuing se goals dart suggests that requiring earned income models is a matter of ideology because from a rational perspective socialsector innovations should all be equal whether they receive government funds or earn income furthermore se is also commonly associated with innovative funding strategies as a means to extend the organizations resource base which may include sources of revenues other than commercial activities namely voluntary or inkind contributions and possibly donations and grant aid themes related to the managerial element in addition to the previous social and entrepreneurial elements typically associated with the concept of se we also identified four themes related to a managerial element in the sample of definitions analyzed profit reinvestment businesslike approach scalability and collective governance we discuss each of these themes below first while some authors argue that profit or surplus reinvestment is important to ensure the legitimacy of se a theme cited in 27 definitions others claim that this is not always the case some social enterprises with commercial activities can legitimately decide to make profits and share them with their shareholders as they may target private investment to ensure funding requirements that require profit sharing relaxing the requirement of profit reinvestment and allowing for profit distribution in se is also aligned with the arguments that se organizations can have diverse legal and organizational forms ranging from nonprofit to forprofit organizations second although most scholars agree that social and business entrepreneurship differ from each other some observe that a businesslike approach or the employment of business principles or methods such as strategy structure norms and values may be common to both types of entrepreneurship the use of such professional practices is also critical to ensure accountability to the constituencies served and for the outcomes created because the discipline of the markets in which social entrepreneurs operate is often not closely aligned with their social mission third scalability is an appealing attribute of se to some scholars because it enables reaching out to as many beneficiaries as possible and legitimizing se through success stories however other academics argue that in some cases growth may not be the best approach to achieve the organizations goals or to have the greatest social impact and that many initiatives stay small and local mirroring the tendency of many microand small businesses not to grow into mediumsized enterprises finally we found the theme collective governance in only six definitions reputed scholars such as defourny and nyssens suggest that the representation and participation of users or customers influence of various stakeholders on decisionmaking and a participative management are often important characteristics of social enterprises however the same authors also observe that empirical research has shown that the singlestakeholder character does not seem to jeopardize the multiplegoal nature of social enterprises suggesting that this attribute may not be a necessary one in conceptualizing se other scholars even fear that a significant focus on stakeholders interests may contribute to lose focus on the essential social goal of se claiming that it is often the case that the social entrepreneur becomes increasingly focused on organizational interests as a means to achieve social impact rather than on social impact itself discussion of stage iidentification of attributes in sum we observe that 12 attributes exhaustively cover the 209 definitions analyzed excluding from the initial 14 themes the entrepreneurial behavior and sustainability of the impact themes because they seem to conceptually overlap with the remaining 12 using frequency as a proxy of the centrality of each attribute and assuming that a central attribute is mentioned in more than ten percent of the total number of definitions we found six central attributes referred to in more than 21 definitions social goals commercial activity innovativeness proactiveness transformational change and profit reinvestment previous studies mention as limitations the tautology often involved in conceptualizing se the different meanings contained in social and entrepreneurship terms and the controversy of the attributes proposed however by systematically analyzing a comprehensive sample of se definitions we provide a more precise picture of the exhaustive list of se attributes and how central each of them is in characterizing se the persistent controversy related to many of the attributes identified points to the contested nature of the se concept this contested nature complicates a straightforward unbiased selection of attributes to conceptualize se and requires additional attention to understand how academics organize them stage iiorganization of attributes in the second stage of good conceptual development podsakoff et al recommend identifying necessary and sufficient attributes or shared characteristics across subsets of cases definitions in our sample combined on average three and up to six themes we found 101 different combinations of themes in our sample there is a wide dispersion of definitions through the different combination of attributes without a specific set of attributes standing out from the wide variety of combinations the most frequent combination repeated in only 29 definitions included social goals and commercial activity attributes emergent se conceptual subtypes we then analyzed the frequency with which pairs of se attributes appear together in se definitions the attributes commercial activity and innovativeness seldom appear together despite being frequently cited in se definitions suggesting there are two different schools of thought combinations between commercial activity and innovativeness with other attributes differ and present little overlap among the plethora of existing attribute combinations it is possible to discern four emergent conceptual subtypes which do not however cover all the spectrum of combinations within the commercial activity school of thought the most representative subtype results from combining only that attribute with social goals or linking them both with proactiveness examples of se definitions within this first subtype are t he process of employing marketbased methods to solve social problems and t he process of identifying evaluating and exploiting the opportunities aiming at social value creation by means of commercial marketbased activities and of the use of a wide range of resources a second conceptual subtype also based on commercial activity results from requiring profit reinvestment as a key characteristic of se conceptualizations within this subtype relate to yunus definition of social business which is described as a selfsustaining organization whose owners never intend to make profits for themselves in the same vein hartigan defines se as businesses in which revenues beyond costs are reinvested in the enterprise in order to fund expansion considering the innovativeness school of thought the variety of attribute combinations is wider and subtypes are less clearcut notwithstanding it is possible to identify a third prominent se subtype combining social goals innovativeness and proactiveness as key attributes of se which eventually includes further attributes such as resourcefulness businesslike approach and scalability within this subtype austin et al define se as an innovative social value creating activity that can occur within or across the nonprofit business or government sectors adding resourcefulness to the previous combination mair and marti define se as a process involving the innovative use and combination of resources to pursue opportunities to catalyze social change andor address social needs a fourth distinct subtype emerges within the innovativeness school of thought by requiring transformational change as a key attribute of se draytons definition of a social entrepreneur is an exemplar within this subtype what defines a leading social entrepreneur first there is no entrepreneur without a powerful new system change idea there are four other necessary ingredients creativity widespread impact entrepreneurial quality and strong ethical fiber martin and osberg and santos also provide definitions within this fourth subtype considering the units of analysis we find that in definitions explicitly including terms related to the commercial activity theme the most common unit of analysis refers to the organizationlevel versus less common individuallevel or processlevel units of analysis however in definitions referring to innovativeness academics tend to use individuallevel or processlevel units of analysis rather than those referring the level of the organization mentioned in 14 of the cases in this se subtype discussion of stage iiorganization of attributes the patterns observed are in line with evidence presented by chliova et al who argue that the se category has historically originated from two different schools of thought based on either commercial activity stage iiidevelopment and refinement of the conceptual definition in the last stages of the concept development process podsakoff et al suggest generating and refining a definition that describes the general nature of the concept in family resemblance concepts barrenechea and castillo recommend turning to the subtypes to gain the differentiation that is lost by the inherent nature of these structures building on other scholars research who noted normative implications underlying the definition of se we investigated how distinct normative ethical positions relate to different se attributes noteworthy we do not aim to oversimply the complexity that characterizes the se concept with this exercise our aim in uncovering different ethical stances is rather to gain understanding on the cooccurrence of specific attributes in different se conceptualizations consequentialist views we found that a significant number of scholars normatively identify se by stressing the social consequences or outcomes of entrepreneurial activities although most ethical stances are implicitly stated peredo and mclean within a consequentialist frame clearly argue that the pursuit of socially valuable outcomes is something worth identifying and fostering whereas probing the mysteries of motivation is not only difficult but of little practical consequence in more radical conceptualizations social goals are an additional happy outcome of entrepreneurial activities as such several scholars ask if there is a difference between se and other forms of entrepreneurship or if the difference is a result of neglect ing to mention the social outcomes and benefits of entrepreneurship work employment belongingness community friendship selfrespect social standing and development of ones capability within consequentialism we also identified other stances that relate to more specific ethical views assuming an act utilitarian view academics often stress the relevance of maximizing value while minimizing harms for society and of resource efficiency requiring the understanding of the competitive environment in which se develops while both arguments relate to a utilitarian stance the centrality of social goals may differ on one hand conceptualizations focusing on the maximization of social value tend to view social goals as a central attribute in se on the other hand from the point of view of resource efficiency some academics dont see the social element as necessarily central in se stating that anyone who claims the cause is all is wrong and the social mission is not a sacred goal as traditionally has been believed but must be understood within the competitive environment within which the organizations operate to define se it is argued that innovativeness or resourcefulness are key attributes to rearrange resources in a productive way proposing that cost efficiency suggests that society could get far more innovative social welfare delivered at a lower cost through a utilitarian lens holding a businesslike approach is critical because s trong leadership and good management of socially entrepreneurial initiatives is important there is always an opportunity cost for the resources being utilized achievement below that which could be achieved is a lost opportunity an unmet need furthermore related with a utilitarian view proactiveness often assumes that rather than being motivated by moral obligation the agent pursues those activities with potential to create positive social and economic outcomes because opportunity seeking behavior goes hand in hand with the financial viability of the opportunity finally scalability might also be a relevant se attribute to attain economies of scale and further pursue resource efficiency regarding the type of good se should pursue we discerned two distinct stances on one hand a view more related to hedonic wellbeing referring social goals as life satisfaction domains or quality of life following a benthamian tradition some academics propose a formula to calculate and compare the amount of social value created among different social interventions because markets do not do a good job of valuing social improvements public goods and harms and benefits for people who cannot afford to pay on the other hand some conceptualizations stress that se should aim at the empowerment of beneficiaries defined as the process of increasing the assets and capabilities of individuals or groups to make purposive choices and to transform those choices into desired actions and outcomes this understanding seems closer to the concept of eudemonic wellbeing which corresponds to the degree to which a person is fully functioning and feels alive thriving and authentic in this vein academics stress the transformational change attribute of the social element that targets the underserved neglected or highly disadvantaged population that lacks the financial means or political clout to achieve the transformative benefit on its own in this light innovativeness plays a key role in finding new solutions for current social problems academics defending an economistic stance note that social goals may be viewed as the means by which profitability is achieved scholars acknowledge that previous contributions suggest both the importance and uniqueness of combining social and economic missions and that social entrepreneurial opportunities may emerge from a reframing which encourages seeing people in need as clients instead of beneficiaries in this frame of thought commercial activity is a required macmillan 2017zahra wright 2016 although few authors explicitly mention the attribute willingness to take risk creating economic value implies taking risks under an economistic view finally denoting a rule utilitarian stance in which moral behavior requires adopting rules based on the consequences they may have some scholars include commercial activity and profit reinvestment as attributes of se commercial activities and markets are needed to ensure resource efficiency and legitimate surpluses however unlimited profit distribution is sometimes viewed as a cause of mission drift and the condition to reinvest surpluses is critical as it reverses the profit maximization principle by benefit maximization principle deontological views when conceptualizing se a group of academics tends to emphasize the morality of the actions under a series of rules rather than defining se based on its consequences as in previously described views we found different deontological ethical stances focusing on motivations that seem to underly the choice of specific attributes of se first several scholars refer to helping people in need as the motivation for se which seems to relate to kants imperfect duty of beneficence however some of such definitions also seem to add a utilitarian twist explaining that to be pursued actions must create a positive net value assuming a clearer deontological stance other academics seem to implicitly hold a kantian view in conceptualizations that refer to moral obligations to attend to social goals as the motivation for entrepreneurial action in this light proactiveness can be understood as the direct action motivated by moral obligation rather than the pursuit of opportunities with value creating outcomes second se conceptualizations that normatively require a collective governance attribute may relate to a habermasian discourse ethics several scholars argue that assuming a collective governance structure contributes to manage tensions among different stakeholders and ensure an ethical conduct through transparency finally evidencing a rightsbased ethical stance some academics view the social element as claims of individuals to the state or other supra entity explicitly and normatively enumerating legitimate social goals as a set of specific human rights for example seelos and mair propose that the scope of the social element is defined by the mdgs and argue that u nless we set boundaries to the scope of se it may be impossible to define the unique characteristics that differentiate it from traditional or business entrepreneurship virtue ethics the number of scholars that explicitly refer to the virtuous character of the social entrepreneur as a requirement to identify se is scarce and refers to earlier articles in the literature martin and osberg speak of courage and fortitude as fundamental attributes of the social entrepreneur perhaps more explicitly drayton claims that social entrepreneurs must hold an ethical fiber and be a good person you instinctively know you can trust because social change usually requires those affected to make several leaps of faithwhich they wont do if they intuitively do not trust the champion of the proposed change discussion of stage iiidevelopment and refinement of the conceptual definition most se conceptualizations relate to a consequentialist paradigm and are seldom associated with deontological or virtue ethics indeed most definitions within the two main schools of thoughtbased either on innovativeness or commercial activityrelate to utilitarian views identifying se phenomena through the social and or economic outcomes produced in line with bruders argument however our data show noteworthy differences among ethical stances related to attributes additionally there is a revealing overlap between the different ethical stances and specific combinations of attributes described in the four previously identified se subtypes the first subtype combining social goals and commercial activity and representing the most common combination of attributes is often associated with an economistic stance assuming the use of competitive markets as a mechanism that ensures ethical behavior in marketbased conceptualizations economic profits are a positive result of value creation and thus ethically acceptable if not desirable second the social business subtype includes profit reinvestment in addition to social goals and commercial activity as key components of se relating with a rule utilitarian view such definitions require the condition of reinvesting legitimate surpluses to differentiate se from commercial entrepreneurship and ensuring businesses focus on maximizing social benefits rather than personal wealth the third se subtype is typically associated with a hedonic act utilitarian view and includes conceptualizations focused on maximizing social value creation rather than on economic value creation or capture this subtype labeled efficiencydriven se requires innovativeness scalability and a businesslike approach as important ingredients to achieve resource efficiency and optimal productivity fourth se definitions that combine social goals innovativeness and transformational change also place a central role on the attribute social goals however social goals are here understood as beneficiaries empowerment and avoidance of their dependence which relates closer to eudemonic wellbeing finally both virtue ethics and deontological views are less popular stances found in se conceptualizations while uncovering these ethical stances provides a fruitful ground in understanding different combinations of attributes it is hardly expected they are reconcilable the prevalence of distinct and irreconcilable normative views defining se is an argument against the applicability of a classical structure to se and supports the family resemblance structure of the se concept contributions conclusion and limitations at an academic level our work contributes to both se and ethics literatures regarding the se literature we propose se follows a family resemblance conceptual structure a less common and often overlooked conceptual structure in the management field the improbable reconciliation of prevailing se conceptualizations previously acknowledged as a contested concept driven by different worldviews is a strong argument against the use of a classical conceptual structure that defines se as a universal set of necessary and sufficient attributes the family resemblance structure is inclusive of the various perspectives of se by uncovering how different attributes are combined into prominent se subtypes and thus allowing the systematization of its scattered understandings our study identifies twelve attributes that comprehensively characterize the se family resemblance concept and relate them with four emergent se subtypes by systematically analyzing the content of 209 academic definitions setting a sound path for operationalizing the se concept and developing rigorous measurement instruments we build on previous studies that suggested clusters of concepts to advance research in se however the attributes identified are characteristics of se with clearer boundaries and less problematic overlaps furthermore our study also described more nuanced meanings of attributes among distinct conceptualizations these findings caution researchers regarding a potential causal heterogeneity among se subtypes although collectively part of the same conceptual space se subtypes may not be substitutable for causal purposes for example organizational tensions are potentially significant in the process of creating an organization that simultaneously pursues social and economic goals but probably less important in other entrepreneurial processes that do not resort to commercial activities to fund operations likewise social innovation is an expected outcome of innovative se activities that promote the creation of new approaches to tackle intractable social goals but is not an obvious consequence of organizations that fund their social goals through commercial activities the family resemblance structure untangles the fallacy that results from using the same se term to label different combinations of attributes much confusion in the se field is a consequence of erroneously assuming that different things are the same because they share the se label additionally assuming a family resemblance structure accommodates the variety of existing se definitions without oversimplifying it in only a few more popular subtypes based on for example commercial activities rather this structure accommodates less common and potentially marginalized definitions such as those based on virtuosity or collective governance this study also contributes to the ethics literature specifically to the ongoing debate on how different normative ethical positions relate to distinct conceptualizations of se previous studies in this field under a consequentialist lens argue that a social mission can only be attested by looking at the practical outcomes of interventions and discuss ethical decisionmaking under the influence of societal power relations defending a deontological stance bruder concludes that se should be normatively grounded on deliberative democracy practices that can legitimately qualify as social beyond a missioncentric maximization principle in our study however by adopting a descriptive stance we uncover a diverse set of ethical views related to the selection of different attributes to define se we conclude that when considered as a family resemblance concept se is not bounded to a unique ethical reasoning but to several our findings indicate that academics predominantly use consequentialist ethical views in defining se specifically relying on act utilitarian and economistic stances deontological and virtue ethics are less frequently reflected in se definitions yet departing from previous studies we refrain from normatively concluding which se conceptualization and respective ethical stance should prevail rather we assume that different ethical views provide legitimacy to distinct se definitions and avoid arguments for the superiority of a specific conceptualization this inclusive understanding of se has important implications to the study of its ethics by incorporating different ethical views predominant and less so researchers can bring to the table several important ethical aspects of se adding to the ethical discussion about the consequences of se its motivations and the virtuosity of social entrepreneurs for example future research could study ses social mission a prominent attribute across se conceptualizations by considering consequentialist or deontological ethical claims related to the former scholars may study how se maximizes the good and minimizes harm to society is a source of hedonic andor eudemonic wellbeing or creates social value while maximizing resource efficiency on the other hand considering se and its mission through the deontological ethical lenses future studies may illuminate motivations emerging from attending to human dignity as a moral obligation or respecting human rights when addressing personal claims upon society assuming a deontological perspective scholars may also investigate how deliberative democracy contributes to solving stakeholders tensions and promoting ethical behavior this study offers academics and practitioners a valuable map of the breadth of existing ethical views underlying the concept of se we acknowledge two noteworthy limitations in our study first the attributes identified reflect the conceptualizations present in a sample of academic definitions despite the vastness of definitions collected and analyzed other attributes may exist in se definitions not included in our sample second the nature of a family resemblance concept is inherently complex and we do not aim to oversimplify it by directly associating the choice of each attribute or combination of attributes with a unique ethical stance in addition distinct ethical stances not referred to as for example the ethics of care may provide fruitful ground to understand the se conceptualizations and are potentially worth exploring in future research appendix see table 3

almost 25 years after dees article on the meaning of social entrepreneurship conceptual controversy persists based on a qualitative analysis of 209 definitions of social entrepreneurship and respective academic articles we argue that the concept follows a family resemblance structure and identify the 12 distinct attributes that comprehensively define it membership in social entrepreneurship is not defined by a case possessing a universally accepted set of criterial features but by carrying shared attributes with other cases the family resemblance structure points to the persistent fallacy of using the same term to label different phenomena and cautions researchers against causal homogeneity assumptions among different conceptual subtypes assuming a descriptive stance we shed light on how distinct ethical positions relate to different definitions of social entrepreneurship among the existing conceptual variety we identify four prominent subtypes and find that marketbased conceptualizations relate to economism the social business subtype relates to rule utilitarian positions efficiencydriven definitions are associated with hedonistic act utilitarian views and the transformational impact subtype is akin to a eudemonic act utilitarian stance

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introduction intimate partner violence or victimperpetrator relationships among current or former intimate partners is widespread across diverse settings 1571 of everpartnered women have reported lifetime physical andor sexual ipv and the risk of exposure is higher during and after pregnancy in india 34 of all women 1549 years have reported some exposure to violence since age 15 two in five evermarried women 1549 years have reported some form of ipv and the reported prevalence of any lifetime ipv varies by state from 7 in himachal pradesh to 61 in bihar international institute for population sciences macro international 2007a the early initiation of breastfeeding and exclusive breastfeeding until 6 months of age are aspects of optimal breastfeeding practices united nations childrens fund world health organization 2003 an estimated 14 million deaths to infants in poorer countries could be averted with optimal breastfeeding yet levels of early initiation and exclusive breastfeeding remain low in many countries in india in 20052006 almost all children 05 years were ever breastfed but only 25 were breastfed within 1 h of birth and this percentage varied widely across states also less than half of infants 05 months and only 28 of those 46 months were exclusively breastfed in diverse settings maternal reported exposure to ipv has been linked with poor outcomes related to child survival health and nutrition 1 breastfeeding and complementary feeding practices are important potential links in the relationship between maternal exposure to ipv and these outcomes in children yet the possible effects of maternal exposure to ipv on infant feeding practices are understudied and the limited available evidence is mixed 2 scholars have proposed two competing hypotheses to explain the relationship between maternal exposure to ipv and breastfeeding the deficit hypothesis suggests that mothers exposed to ipv may have behavioural or physiological difficulties with breastfeeding behaviourally an ipvexposed mother may attach distressing sexual meanings to breastfeeding and the breasts engage in negative coping behaviours that are associated with the cessation of breastfeeding or may be physically injured anxious or depressed all of which may impair her ability to breastfeed her infant the compensatory hypothesis suggests that mothers exposed to 1 data on exposure to ipv for the literature cited here typically comes from womens selfreport as does the data on ipv used in the analysis presented in this paper hereafter reported exposure is implied in all references to ipv exposure 2 in an extensive review of the literature yount et al identified only eight studies that have assessed maternal exposure to ipv and infant feeding practices of which most were based on crosssectional designs and small purposive samples two case studies from australia and brazil revealed mixed experiences of breastfeeding in mothers exposed to ipv one crosssectional facilitybased study in hong kong suggested that exposure to ipv in pregnancy was negatively associated with the initiation of breastfeeding whereas a small crosssectional facilitybased study in the united states found no association between exposure to physical or sexual ipv and either the initiation or duration of breastfeeding using data from a large crosssectional study of women participating in the pregnancy risk assessment monitoring system in the united states silverman et al found that women exposed to ipv in pregnancy were less likely than unexposed women to initiate breastfeeding and were more likely to cease breastfeeding however these relationships were not statistically significant after adjusting for smoking status and demographic measures in one prospective cohort study maternal exposure to ipv was negatively associated with engagement in any breastfeeding 6 weeks after birth but information about ipv was not systematically collected and potential confounders were not controlled key messages • intimate partner violence is common but its potential adverse effects on infant feeding practices are understudied • we assessed associations of lifetime ipv with infant feeding practices in 3552 motherinfant dyads in india • compared to their counterparts mothers exposed to any ipv and to any physicalsexual ipv had higher adjusted odds of nonexclusive breastfeeding • addressing ipv and its aftereffects in the perinatal period may improve infant feeding growth and development in india and similar settings ipv may be more sensitive to their childs needs and exhibit certain positive parenting behaviours including more optimal infant feeding practices by mothers who know the recommended guidelines however feeding an infant foods too early may also be a compensatory response to ipv exposure especially if certain foods are scarce and valued or if early complementary feeding is seen as beneficial compensatory parenting such as becoming a more effective and responsive mother has been observed in some mothers exposed to ipv who have preschoolaged and younger children the evidence base for the association between ipv and breastfeeding practices in india is particularly limited a crosssectional study of 600 motherinfant dyads in rural andhra pradesh india did not detect a significant association between maternal report of physical ipv and exclusive breastfeeding however the results suggested that mothers with greater financial autonomy were more likely to breastfeed exclusively and their greater decisionmaking power was positively associated with infant nutritional outcomes including weightforage zscore and weightforlength zscore although there is limited evidence on the relationship between ipv exposure and breastfeeding practices in india maternal exposure to ipv has been associated with poorer nutritional outcomes including wasting and stunting in children 1235 months a higher risk of neonatal perinatal and child mortality and lower rates of child immunization exposure to ipv has also been shown to be negatively associated with maternal health prenatal care and mental health in india in this analysis we use logistic regression to assess the unadjusted and adjusted associations of maternal reported lifetime exposure to either any ipv or to physical or sexual ipv with the timing of breastfeeding initiation exclusive breastfeeding in the prior 24 h and complementary feeding in the prior 24 h in 3552 dyads of mothers and infants յ180 days who took part in the crosssectional 20052006 national national family health survey given the available evidence from india linking ipv exposure with poor childhood nutrition as well as maternal autonomy with adherence to recommended breastfeeding practices we expect to find that maternal exposure to ipv is associated with suboptimal infant feeding practices consistent with the deficit hypothesis materials and methods sample and data the data for this study come from the 20052006 national family health survey for india a crosssectional household survey designed to be nationally representative with a stratified multistage probability sample design the survey was conducted from november 2005 to august 2006 a total of 124 385 neverand evermarried women 1549 years received a womens questionnaire which among other questions included a birth history and detailed questions about the health care and feeding practices of children born in the prior 5 years of these respondents 83 703 were selected randomly to receive an ipv module a shortened adaptation of the revised conflict tactics scale this module included questions about violence since age 15 for neverand evermarried women as well as questions about lifetime and prioryear violence perpetrated by the current or most recent husband for evermarried women the unit of analysis for this study is the motherinfant dyad to be included in the final sample infants had to be 180 days old or younger at the time of the mothers interview the mother had to be selected for and must have completed the ipv module and all data on infant feeding practices and ipv had to be nonmissing of 256 782 total motherchild dyads documented in the birth histories 5183 motherinfant dyads were potentially eligible for inclusion in our final sample based on the age of the infant at the time of interview of these dyads 3790 mothers had been selected for the ipv module but 28 of these mothers were not interviewed because of a lack of privacy or other unrecorded reasons excluding another 210 mothers with missing data on infant feeding practices or ipv yielded a final sample of 3552 motherinfant dyads compared with mothers included in the analysis mothers who were selected for the ipv module but were excluded from this analysis because of missing data were more likely to have bottlefed their infant and to have fed their infant liquids or solids in the prior 24 h thus excluded mothers were less likely than included mothers to have exclusively breastfed their infant although the two groups did not differ on any of the covariates included in the analysis women who had been excluded from the analysis were marginally more likely to report any physical or sexual ipv fortyfour mothers had missing covariate data on religion completed grades of schooling or the gap between the mothers and her husbands completed grades to retain these observations in the analysis we imputed the mean value for grades of schooling and the modal value for categorical variables based on the sample with values for these variables outcomes two of five binary outcomes measured whether or not the infant was breastfed within 1 hour after birth and exclusively in the prior 24 h three complementary feeding outcomes which are not recommended for infants this age measured whether or not the infant in the prior 24 h drank from a bottle with a nipple ate solid or semisolid foods and drank liquids other than breast milk exposures two measures for exposure to ipv captured whether or not the mother reported any lifetime exposure to any ipv or physical or sexual ipv these measures were constructed from separate questions about lifetime exposure to specific forms of physical ipv specific forms of sexual ipv and specific forms of psychological ipv we used lifetime reported ipv as the exposure rather than specifying a time frame because any such exposure has been linked with longterm detrimental health outcomes for women and children covariates covariates considered for analysis were those that may confound the relationships of interest given their associations with both ipv and infant feeding practices these covariates included the childs gender analyses relative frequencies were calculated for all outcomes exposure variables and covariates either raoscott chisquare tests or ttests of association adjusting for the complex survey design were estimated between the five feeding outcomes and exposures and between the covariates and exposures logistic regression then was used to assess the associations of maternal exposure to ipv and infant feeding practices for each of the five feeding outcomes we estimated two unadjusted logistic regression models to assess the relationship of each feeding practice with exposure to either any ipv or any physical or sexual ipv we then estimated the same set of models adjusting for the covariates listed earlier results are presented as odds ratios and 95 confidence intervals significant and marginally significant odds ratios with common patterns are discussed results sample characteristics on average mothers were 244 years old and had 17 everborn children excluding the index infant mothers had completed a mean 44 grades of schooling half had less schooling than their husband and 17 had more schooling than their husband a majority was hindu about onefourth was living in urban areas and more than half was living in the central and eastern regions of india over onethird of mothers reported ever being exposed to any ipv and 36 reported ever being exposed to physical or sexual ipv thus the mothers reporting any ipv and reporting physical or sexual ipv were largely overlapping mothers most often reported ever experiencing physical ipv followed by psychological and then sexual ipv of women reporting exposure to any ipv 74 reported experiencing such violence in the prior year while 72 of women reporting ever exposure to physical or sexual ipv reported such violence occurring in the prior year compared with their unexposed counterparts women exposed to any ipv were less often living in an urban area were more often in the lowest two wealth quintiles had higher parity excluding the index infant had fewer completed grades less often had more schooling than their husband more often were the wife of the household head were older more often had a female infant more often selfidentified as hindu and more often lived in the central and eastern regions of india similar differences were observed in the characteristics of women exposed to physical or sexual ipv in comparison to those unexposed around 33 of mothers breastfed within 1 h of birth and this percentage was lower among mothers who were exposed to ipv than among those who were unexposed the practice of bottle feeding with a nipple in the prior 24 h did not differ by ipv exposure status more than half of all mothers fed their infant other liquids in the prior 24 h and mothers exposed to any ipv and to any physical or sexual ipv engaged in this practice marginally more often than their counterparts few mothers fed their infant solid foods in the prior 24 h and this practice did not differ significantly by exposure to ipv around 45 of mothers reported exclusively breastfeeding their infant in the prior 24 h and this percentage was marginally lower among mothers exposed to physical or sexual ipv than their counterparts almost all infants were being breastfed at the time of the survey regression results compared with their counterparts mothers exposed to any ipv and to physical or sexual ipv had lower unadjusted odds of breastfeeding immediately after birth and marginally higher unadjusted odds of feeding liquids in the prior 24 h mothers exposed to physical or sexual ipv had marginally lower unadjusted odds of exclusively breastfeeding in the prior 24 h in general the relationships of exposure to ipv and feeding practices became stronger with adjustment for covariates compared with their unexposed counterparts mothers exposed to any ipv and to physical or sexual ipv respectively had lower adjusted odds of exclusively breastfeeding their infant as well as higher adjusted odds of giving their infant liquids mothers exposed to physical or sexual ipv also had higher adjusted odds than their counterparts of feeding their infant solids in this period the adjusted odds of breastfeeding immediately after birth and of bottle feeding did not differ with exposure to either measure of ipv computing the average marginal effect of exposure to any ipv on the probability of feeding an infant liquids suggests that exposure to any ipv increases the probability of feeding liquids by 56 percentage points whereas exposure to physical or sexual ipv increases the probability of feeding liquids by 64 percentage points 3 in comparison the ame of exposure to any ipv on the probability of feeding solids is 16 percentage points and the ame of exposure to physical or sexual ipv on feeding solids is 24 percentage points thus exposure to ipv is associated with an increased risk of engaging in nonexclusive breastfeeding mainly as a result of feeding infants liquids because few women reported feeding infants solid foods in the prior 24 h we tested the sensitivity of our results to the inclusion of other indicators of physical violence exposure to physical violence by parents after age 15 and forced sexual acts by someone other than a husband in either childhood or adulthood very few mothers in the sample reported exposure to forced sexual acts by someone other than a husband and a small number reported exposure to physical violence at the hands of a parent after age 15 in general the inclusion of these covariates did not substantially alter the estimated association of exposure to any ipv or to physical or sexual ipv with breastfeeding outcomes although some models indicated a significant association between exposure to forced sexual acts by someone other than a husband and negative breastfeeding behaviours these results should be interpreted cautiously as few women reported exposure to this type of violence discussion ipv is a global problem that adversely affects maternal and child health this paper examined the unadjusted and adjusted associations of maternal exposure to ipv with infant feeding practices an important topic given high rates of ipv suboptimal feeding practices and scant and equivocal findings regarding their potential links this analysis extends the evidence base in several ways first we focus on the case of india a diverse country in which onethird of the worlds malnourished children live second we leverage a large nationally representative sample of motherinfant dyads which addresses the small sample sizes of most prior studies third we examine two measures for lifetime exposure to ipv a global measure capturing any prior physical sexual or psychological ipv and a specific measure capturing any prior physical or sexual ipv our specification of global and specific forms of ipv addresses the tendency of prior research to not state the form of ipv under study or to focus only on physical or sexual forms finally we consider multiple feeding practices including ones previously studied and others never studied such as the timing of initiation exclusive breastfeeding and multiple complementary feeding practices on the one hand the combined lower adjusted odds of exclusive breastfeeding among mothers 3 the average marginal effect is calculated by computing the marginal effect for each respondent ie the difference in predicted probabilities of engaging in a particular infant feeding practice assuming the individual reported exposure to ipv vs did not report exposure to ipv and averaging these marginal effects across the sample exposed to ipv and their higher adjusted odds of providing other liquids or foods are consistent with the deficit hypothesis following this interpretation mothers exposed to ipv may be less able physiologically or behaviourally to breastfeed exclusively and so rely on complementary foods to nourish their infants on the other hand these results could also be viewed as consistent with the compensatory hypothesis if women exposed to ipv are unaware of the guidelines for infant feeding and tend to feed their children complementary foods that are scarce or valued in the local context yet additional analyses showed that mothers exposed to ipv were not more likely to feed their infant potentially valued foods such as baby food thus collectively our results corroborate a deficit model for the effects of maternal exposure to ipv on infant feeding practices and highlight the potentially important intergenerational effects of ipv at a critical stage of early childhood with potential longterm effects on the wellbeing of exposed children their families and the larger society notably our reliance on crosssectional retrospective maternal reports of ipv and infant feeding practices precludes causal inferences still most adjusted associations were highly significant and persisted despite potential selection and response effects that would likely bias associations towards the null specifically women who were excluded from the analysis because of missing data on ipv or breastfeeding behaviours were more likely to engage in nonrecommended breastfeeding practices and were marginally more likely to be exposed to physical or sexual ipv these patterns and the possible nondisclosure of exposure to ipv by some mothers in the analysis suggest that our estimates may reflect lower bounds for the effects of maternal exposure to ipv and engagement in nonrecommended infant feeding practices because the nfhs3 collected data on exclusive breastfeeding using a 24 h recall we were unable to determine the association between ipv exposure and engagement in exclusive breastfeeding for the full first 6 months of life or between ipv exposure and the precise timing of the introduction of nonrecommended foods the reliability of the measure of exclusive breastfeeding was improved by the inclusion of a detailed foods list in the nfhs3 nevertheless greater insights into the relationship between maternal exposure to ipv and infant feeding practices could be gained by collecting more detailed measures for the consumption of breast milk other liquids and solid foods in the prior 24 h and by using calendar methods to identify the duration of exclusive breastfeeding and the timing of the first introduction of other liquids and solid foods longitudinal studies of ipvexposed and unexposed motherinfant pairs in which biomarkers of maternal and infant stress breast milk volume and breastmilk composition are collected with observations and reports of maternal and infant behaviour would clarify biological and behavioural causal pathways mothers rationales for selected feeding practices and the role of infant feeding as a mediator between ipv and child growth other relationships that warrant study are those between maternal exposure to ipv their autonomy and feeding practices in india a husbands controlling behaviour has been strongly associated with his perpetration of ipv and enhanced maternal autonomy in decisionmaking may be positively associated with infant feeding practices in rural areas this pathway may be relevant in parts of india and other south east and southeast asian settings where more rigid forms of patriarchy persist although india is a large and diverse country in which the population of malnourished children reflects a high percentage of the malnourished children globally similar research is needed to corroborate or refute our findings in other contexts optimal infant feeding practices help to ensure appropriate nutrition in early life which is essential for healthy growth and development this research underscores the intergenerational consequences of maternal exposure to ipv and suggests a programmatic need to screen perinatally for ipv in poor settings to identify mothers at higher risk of nonexclusive breastfeeding as well as nonrecommended complementary feeding practices support to mothers should include not only the promotion of optimal feeding practices but also efforts to mitigate ipv and the physiological stress that may ensue from exposure success in these efforts would enhance maternalinfant interactions in ways that would further support optimal infant feeding practices source of funding none conflicts of interest the authors declare that they have no conflicts of interest contributions kmy initiated the idea for this research as part of her research programme on the intergenerational effects of intimate partner violence szb and kl prepared the data and conducted the statistical analysis all authors contributed to the study design and writing of the manuscript all authors read and approved the final version

intimate partner violence ipv is widespread yet research is thin and equivocal regarding its potential adverse effects on infant feeding practices with a national sample of 3552 mothers and infants aged 180 days or younger from the 20052006 national family health survey for india we used logistic regression to estimate the unadjusted and adjusted associations of maternal reported lifetime exposure to any ipv and to physical or sexual ipv with feeding practices at birth and in the prior 24 h compared with their unexposed counterparts mothers exposed to any ipv and to any physical or sexual ipv had higher adjusted odds of giving their infant liquids aor 132 95 confidence interval ci 104166 aor 137 95 ci 108175 respectively and thus lower adjusted odds of exclusively breastfeeding their infant in the prior 24 h aor 078 95 ci 062098 aor 074 95 ci 058095 mothers exposed to physical or sexual ipv also had higher adjusted odds of feeding their infant solids in the prior 24 h aor 150 95 ci 101223 exposure to ipv was not significantly associated with breastfeeding immediately after birth or with bottle feeding in the prior 24 h perinatal screening for ipv and addressing ipv and feeding practices in exposed mothers may improve maternal health and infant nutrition in similar settings

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introduction maternal and child health in the us despite the us being an industrialized country with advanced medical technologies maternal and child health outcomes in the us lag behind other developed countries while 157 of 183 countries reported decreases in maternal mortality in the last decade the maternal mortality rate in the united states more than doubled between 2000 and 2014 and the country has the second highest maternal mortality rate among the thirtyone members of the organization for economic cooperation and development 12 moreover the us infant mortality rate of 61 infant deaths per 1000 live births shares equally poor rankings and has also recently reversed course on progress made 3 vast geographic racial and ethnic disparities underlie these and nearly all mch outcomes in the us the preventable nature of most mortality in maternal and infant populations renders these disparities indefensible and requires urgent action of multidisciplinary stakeholders 4 social determinates of mch improving mch relies on a deep understanding of the contributors to disparities in health outcomes health professionals increasingly recognize that health outcomes are profoundly shaped not just by biological factors but also by a range of other factors collectively categorized as social determinants of health according to the world health organization sdoh are the conditions in which people are born grow live work and age 5 this constellation of environmental political economic social and structural factors contribute to 60 percent of preventable mortality 67 sdoh have significant relevance to mch for example increasingly research has pointed to neighborhood and other geographic boundaries as important determinants of perinatal and infant health adverse birth outcomes have been found to be associated with neighborhoodlevel contextual factors including rates of poverty rent burden residential segregation educational and income attainment and violent crime 8 9 10 11 12 13 social determinants affect all individuals to varying degrees however there are populations of mothers disproportionally disadvantaged by these factorsmost notably black hispanic and american indian mothers 14 in the united states geographic racial and ethnic disparities present across most mch outcomes are rooted in pervasive structural racism structural racism is defined as a system where public policies institutional practices and cultural representations work to reinforce and perpetuate racial inequity 15 structural racism in healthcare and social service delivery contributes to inequitable experiences in access to and quality of care in maternal health racial disparities have been identified even in access to pain management during childbirth 16 the pervasive toll of racism contributes to higher risks for a range of medical conditions among black mothers such as pregnancyrelated high blood pressure and mental health conditions that threaten their lives and their infants lives 1617 geographic disparities in maternal and infant health outcomes have also intensified over the past decade with an expeditious decline following the epidemic of maternity ward closures in rural communities 1819 these closures have been more dramatic in counties with a higher percentage of black women 20 planning to improve maternal and child health city and regional planning is a distributive system influencing sdoh and patterns of health across a community including maternal and child health planners stated goals are to maximize the health safety and economic wellbeing of all people living in communities 21 planners help create a broad vision for the future of communities integrating the diverse building blockstransportation housing infrastructure etcinto a cohesive community plan through policy tools such as local laws tax exemptions and public financing however planners have been reticent to utilize these tools to intervene in social determinants of maternal health to specifically plan for environments supportive of pregnant women mothers and infants inadequacies in planning for women and families have been highlighted in critiques of suburbia as an isolating urban form occupied by but not designed for the daytime activities of women and children 22 housing structure too has not been built for the needs of women and families particularly working mothers 23 outside of the suburbs acknowledgement of the feminization of povertythat women with children constitute a large majority of lowincome familieshas not led to supportive planning practice for families 2425 few comprehensive community plans include specific consideration of children 26 today planning has not openly grappled with the need for increasingly popular social policies like universal childcare or family leave and municipal governments have often failed to provide adequate services like public transportation to caregivers in the locations where they can be used 2325 there are few contemporary examples within the planning discipline of plans that utilize maternal and early child health indicators such as infant and child mortality childhood blood lead levels racial disparities in low birth weights and availability of childcare providers 27 the american planning associations healthy planning a gold standard guide for assisting practicing planners in engaging in healthier community planning does not mention maternal health children are incorporated only when the health outcome of concern is childhood obesity and access to greenspace and physical activity are the solution likewise the apas healthy plan making designed to improve comprehensive planning for health gives similarly little attention to maternal and child health though planners may not be focusing explicitly on maternal and child health as part of their professional duties their desire to do so is strong a survey of the profession indicates that 98 of practicing planners believe they have a role to play in planning familyfriendly communities through addressing housing design transportation and schools similarly mch researchers and practitioners have yet to fully realize the disciplines voice on local planning and have been slow to operationalize robust interdisciplinary partnerships to assess and plan to reduce inequities in mch that are rooted in structural disparities as attention towards both the social determinants of health and planning for motherandchildfriendly communities evolves we developed a set of indices that function within a larger comprehensive needs assessment to understand the mch landscape in local communities the mch need indices offer a systematized way to identify the geographic disparities in health influenced by deeprooted structural issues in the communities particular attention was given to examining the broader range of determinants of maternal and child health including community environment and placebased indicators we piloted these need indices in pennsylvania as part of a larger federally mandated public health program assessment the data and process of these indices is closely aligned with the goals of the comprehensive planning process providing an opportunity for incorporating this maternal and child health focus into planmaking furthermore the countylevel scale of the indices aligns with countylevel planning more common in rural communities making the indices useful for rural planners with few other resources for engaging in placebased improvements in maternal and child health in this paper we describe the development and results of the index and provide guideposts for how these measurements of social determinants of maternal and child health could be better incorporated into traditional planning processes methods selection of indicators for mch needs in an effort to provide a comprehensive view of the landscape of family and community wellbeing and the structural determinants of mch we selected 66 indicators within 6 domains to derive the mch need indices the six domains include perinatal infant and child outcomes socioeconomic status substance use child safety and maltreatment environment and community and childcare these indicators were informed by life course and ecosocial theories 2829 life course theory asserts that the development and maintenance of health is influenced by biological environmental behavioral and social factors across the lifespan and that the impacts of these influences on an individual are cumulative 30 ecosocial theory describes a social production of disease rooted in the interplay between biological processes and social conditions ecosocial theory is a framework for identifying and understanding health inequities in populations and elevates the role of societal systems including historical political economic and social systems 31 in accordance with these theories the indicators included in this index feature resourcefocused measures that reflect the economic structural and historical contexts of communities alongside outcomefocused indicators that are direct measures of health status see table 1 for the full list of indicators data source and definitions for indicators most indicators were derived from raw data for pennsylvania counties accessed from publicly available administrative data and national or regional survey data we also derived countylevel estimates for indicators using data which are not available in public aggregate data but are administrative data processed by each state including birth certificate records and medical billing claims data these data sources were important for creating indicators with a high degree of specificity to the mch population the indicators developed using these state administrative data files included maternal depression wellbaby visits young child wellchild visit postpartum highrisk opioid use pregnancy and postpartum substance use disorder abuse against pregnant and postpartum women infant nonsuperficial injury and young child nonsuperficial injury in the primary domain need analyses raw data was standardized to the county level data manipulations were performed as needed to standardize metrics for comparisons across counties for example when the raw data only contained absolute numbers appropriate denominators were added to create rates to account for the difference in population size when comparing county estimates see table 1 for indicator definitions see supplementary 1 for the data year of each indicator and the statewide statistics of the derived indicators in 67 pennsylvania counties see supplementary 2 for a detailed description of how the indicators were obtained and measured we chose counties as units in primary analyses with the following justification this study is part of a larger federally mandated countybased needs assessment overseen by the health resources and services administration 32 in accordance with federal funding streams for maternal and child health programming state public health officials most frequently use counties as geographic units when allocating resources for communitybased maternal and child public health services and the approach of using county as a primary geographic unit for evaluating community needs is consistent with existing widely used population health needs assessments and ranking systems such as the county health rankings and roadmaps 33 by ranking the health of nearly every county in the us chr r compiles countylevel measures from a variety of national data sources and ranks counties within each state on a selected set of health outcomes and healthrelated factors the need indices in our study focused specifically on maternal and child populations and further refined existing countylevel indicator systems to support maternal and child health although data at more refined geographies can provide important information on meaningful withincounty heterogeneity including racial and economic health disparities subcountylevel data are often less accurate or accessible than countylevel data qualitative methodologies including purposively sampled surveys or focus groups are appropriate mechanisms for identifying disparities that may be masked in countylevel data review need score on each indicator quartiles were used to define counties with elevated need this quartilebased method was chosen for the following reasons first as a rankingbased method it aligns well with the maternal and child health bureaus guidance for defining atrisk communitiesatrisk communities are those for which indicators in comparison to statewide indicators demonstrated that the community was at greater risk than the state as a whole 32 second it accounts for the nonnormal distribution of most countylevel estimates and therefore performs better than zscorebased methods that assume normal distribution of county estimates third as a rankingbased approach it is stable when the absolute county estimates change significantly over the years as new data are updated while the relative level of need between counties remains generally stable over time in this quartilebased method if a countys estimate on any specific indicator is within the top 25 of state distribution of the indicator estimates the county was defined as having elevated need for the indicator for a small number of indicators for which it was assumed that higher estimates indicate better resources and therefore better population health outcomes a county was defined as elevated need if its estimate is within the lowest 25 of state distribution of that indicator a composite need index on each domain for each of the six domains a countys domain composite need score is calculated as the weighted average of the need scores of the indicators within that domain to account for the heterogeneity between indicators in their data quality and proximity of influence on maternal and child health a weighting scheme was used the following metrics were considered in the weight scheme whether or not the indicator was referenced as a requirement in official federal guidance for needs assessment protocols proximity of impact on maternal and child health data recency strength of data collection methodology and specificity of the population of reference in the indicator a weight for each indicator was calculated by adding the above metrics see supplementary 3 for a description of how the weight was calculated for each indicator domain need score was then categorized into a need index using a quartilebased method a county was categorized as having elevated need in a domain if the countys composite need score ranked within the top 25 of all pennsylvania counties as having low need if within the bottom 25 and the rest of the counties as moderate need subcounty analyses in a state as large and diverse as pennsylvania a countylevel analysis may not be sufficient for revealing locallevel variation to provide a closer view of local need and to avoid masking underlying intracounty disparities we included a subcounty analysis of a set of indicators on which zipcodelevel estimates are available this analysis is especially useful for counties with high population density or in counties with significant income or geographic variation twelve counties were chosen for zipcodelevel assessments we used an empirical approach to identify counties with significant regional heterogeneity the approach used the indicator poverty rate for children under 5 and calculated the percentage of zip codes within each county that fall into the low and elevated need categories and selected a list of counties with more than 20 of zip codes in the elevated need category and more than 20 of zip codes in the low need category counties meeting both thresholds were included zip codelevel need indices were generated using the same method as countylevel need indices by comparing zip code estimates to the state quartiles as described above results are presented visually as maps results indicatorlevel results tables 2 and 3 represent the indicators need scores and a composite domain need index for two domains as examples the perinatal infant and child outcomes domain is used as an example for an outcomefocused domain in which most indicators are direct health outcome measurements the community and environment domain is used as an example for a resourcefocused domain in which most indicators reflect the economic and environmental context that shape resource availability with downstream effects on health in each table we present the results for six counties as examplestwo counties in each of three categories of a domain composite need index in table 2 the overall need for the whole perinatal infant and child outcomes domain was summarized into domain composite need score and need index the need score was determined as a weighted sum of a countys need scores on all indicators within the domain in table 3 we also calculated composite need score and index by summarizing indicators within the community and environment domain grey cells show the need indices we created for each county 1 see table 1 for detailed definitions data sources and data year of indicators nicu newborn intensive care unit 2 indicator need score was defined using a quartilebased method for most indicators in this domain for which it was assumed that higher estimates indicate worse population health outcomes a county was defined as having elevated need for the indicator if the countys estimate on the indicator is within the top 25 of state distribution for two indicators in this domain for which it was assumed that higher estimates indicate better resources and better population health outcomes a county was defined as having elevated need for the indicator if the countys estimate on the indicator is within the lowest 25 of state distribution 3 a countys domain composite need score is calculated as the weighted average of the need scores of the indicators within that domain the following metrics were considered in the weighting scheme whether or not us maternal and child health bureau has referenced it as a requirement in official guidance direct impact on maternal and child health data recency strength of data collection methodology and specificity of the population of reference in the indicator a weight for each indicator was calculated by adding the above metrics the weight assigned on each indicator was presented as the third row of the table 4 a county was categorized as having elevated need in this domain if the countys composite need score ranked within the top 25 of all pennsylvania counties as having low need if within the bottom 25 and the rest of the counties as moderate need grey cells show the need indices we created for each county 1 see table 1 for detailed definitions data sources and data year of indicators snap us supplemental nutrition assistance program wic special supplemental nutrition program for women infants and children 2 indicator need score was defined using a quartilebased method for some indicators in this domain for which it was assumed that higher estimates indicate worse population health outcomes a county was defined as having elevated need for the indicator if the countys estimate on the indicator is within the top 25 of state distribution for the rest of the indicators in this domain for which it was assumed that higher estimates indicate better resources and better population health outcomes a county was defined as having elevated need for the indicator if the countys estimate on the indicator is within the lowest 25 of state distribution 3 a countys domain composite need score is calculated as the weighted average of the need scores of the indicators within that domain the following metrics were considered in the weighting scheme whether or not mchb has referenced it as a requirement in official guidance direct impact on maternal and child health data recency strength of data collection methodology and specificity of the population of reference in the indicator a weight for each indicator was calculated by adding the above metrics the weight assigned on each indicator was presented as the third row of the table 4 a county was categorized as having elevated need in this domain if the countys composite need score ranked within the top 25 of all pennsylvania counties as having low need if within the bottom 25 and the rest of the counties as moderate need the results presented in tables 2 and3 show the diverse landscape of health behaviors health and social services access and environmental exposures present across counties in a single us state table 2 shows that there was large heterogeneity in breastfeeding initiation rates across pennsylvania with some counties exhibiting near universal breastfeeding at hospital discharge and other counties with near 50 of live births not breastfed at discharge related to recommended preventive care utilization early prenatal care initiation was common in more counties than was ontime wellchild visits for infants and young children in 39 of 67 counties three out of every four births were to mothers who initiated prenatal care in the first trimester conversely only 22 counties met or exceeded the american academy of pediatrics recommendation of six or more wellbaby visits in the first year of life and children aged 15 in 11 counties had on average less than 1 wellchild visit per age year table 3 shows that there was also substantial heterogeneity across indicators in the community and environment domain while some counties had as many as half of the census tracts designated low income and low access defined by the united states department of agriculture as 30 or more of residents live over 10 miles from a food store other counties had no lowincome and lowaccess census tracts similar variation was observed in libraries per capita in nine counties more than 1 in 10 children experienced elevated blood lead levels moreover the availability of healthcare resources varied widely across the state the number of community health centers per 100000 residents had a wide range across the 67 counties while most counties had more than three primary care physicians per 1000 residents 37 out of the 67 counties had no pediatric dentists overall domain results in addition to the above two domains we used the same approach and calculated the composite domain need indices for the other four domains figure 1 presents the composite need indices of each county on the socioeconomic status domain substance use domain childcare domain and child safety and maltreatment domain of the 67 counties in pennsylvania 23 counties did not meet the elevated need threshold for any of the six domains 44 counties reached elevated need status in at least one domain and 15 counties met elevated need thresholds in three or more domains concentrations of need were dispersed across rural urban and suburban counties in the state the results presented in tables 2 and3 show the diverse landscape of health behaviors health and social services access and environmental exposures present across counties in a single us state table 2 shows that there was large heterogeneity in breastfeeding initiation rates across pennsylvania with some counties exhibiting near universal breastfeeding at hospital discharge and other counties with near 50 of live births not breastfed at discharge related to recommended preventive care utilization early prenatal care initiation was common in more counties than was ontime wellchild visits for infants and young children in 39 of 67 counties three out of every four births were to mothers who initiated prenatal care in the first trimester conversely only 22 counties met or exceeded the american academy of pediatrics recommendation of six or more wellbaby visits in the first year of life and children aged 15 in 11 counties had on average less than 1 wellchild visit per age year table 3 shows that there was also substantial heterogeneity across indicators in the community and environment domain while some counties had as many as half of the census tracts designated low income and low access defined by the united states department of agriculture as 30 or more of residents live over 10 miles from a food store other counties had no lowincome and lowaccess census tracts similar variation was observed in libraries per capita in nine counties more than 1 in 10 children experienced elevated blood lead levels moreover the availability of healthcare resources varied widely across the state the number of community health centers per 100000 residents had a wide range across the 67 counties while most counties had more than three primary care physicians per 1000 residents 37 out of the 67 counties had no pediatric dentists overall domain results in addition to the above two domains we used the same approach and calculated the composite domain need indices for the other four domains figure 1 presents the composite need indices of each county on the socioeconomic status domain substance use domain childcare domain and child safety and maltreatment domain of the 67 counties in pennsylvania 23 counties did not meet the elevated need threshold for any of the six domains 44 counties reached elevated need status in at least one domain and 15 counties met elevated need thresholds in three or more domains concentrations of need were dispersed across rural urban and suburban counties in the state table 4 presents the correlation between need index on perinatal infant and child outcomes domain and the need indices on the other 5 domains supplementary 4 further presents the correlations between the 6 domains overall patterns of correlated risks were not strongly identifiable each countys profile of risk and strength has unique components among the 16 counties at elevated need for the perinatal infant and child outcomes domain 7 of them were also at elevated need on the socioeconomic status domain and 8 of them were also at elevated need on the child safety and maltreatment domain table 4 presents the correlation between need index on perinatal infant and child outcomes domain and the need indices on the other 5 domains supplementary 4 further presents the correlations between the 6 domains overall patterns of correlated risks were not strongly identifiable each countys profile of risk and strength has unique components among the 16 counties at elevated need for the perinatal infant and child outcomes domain 7 of them were also at elevated need on the socioeconomic status domain and 8 of them were also at elevated need on the child safety and maltreatment domain socioeconomic status domain composite need index subcounty results subcounty results for philadelphia county are included in this manuscript figure 2 presents the need indices of philadelphia county for three indicators at the zip code level philadelphia county displays significant heterogeneity across zip codes on poverty preterm birth and high school completion of mothers in general neighborhoods near the geographic center of philadelphia experience higher needs than the rest of the county subcounty results subcounty results for philadelphia county are included in this manuscript figure 2 presents need indices of philadelphia county for three indicators at the zip code level philadelphia unty displays significant heterogeneity across zip codes on poverty preterm birth and high ool completion of mothers in general neighborhoods near the geographic center of philadelphia erience higher needs than the rest of the county discussion incorporating social determinants in evaluating maternal and child health needs needs assessments are a critical public health and planning tool but the process for creating comprehensive product is challenging previous maternal and child health needs assessments hav sometimes failed to achieve maximum community benefits because measurement metrics have bee limited to proximal health outcomes overlooking the full range of factors including factors with the purview of planning that influence maternal and child health 34 this approach is reflected the healthcare system too efforts to improve maternal outcomes have often focused on informing o encouraging individuals to modify behaviors without taking into account their physical and soci environments this method has failed to reduce health inequalities and led to disappointing pattern discussion incorporating social determinants in evaluating maternal and child health needs needs assessments are a critical public health and planning tool but the process for creating a comprehensive product is challenging previous maternal and child health needs assessments have sometimes failed to achieve maximum community benefits because measurement metrics have been limited to proximal health outcomes overlooking the full range of factors including factors within the purview of planning that influence maternal and child health 34 this approach is reflected in the healthcare system too efforts to improve maternal outcomes have often focused on informing or encouraging individuals to modify behaviors without taking into account their physical and social environments this method has failed to reduce health inequalities and led to disappointing patterns such as an increase in preterm births 3536 in this needs assessment we incorporated sdoh through a range of environmental political economic social and structural factors linked to maternal and child health outcomes in particular we incorporated measures for which there is evidence of interventions to reduce social inequalities in health stress early life social exclusion work employment social support food and transportation 37 although there is no simple solution to the complex problem of health disparities promising and knowledgebased directions for action have been explored including economic development initiatives targeting and engaging disadvantaged communities communityfocused initiatives that can lead to healthier communities federal grant programs targeted to provide comprehensive family planning services and preventive health services 38 and home visitation programs giving pregnant women and families particularly those considered atrisk necessary resources and skills to be physically and emotionally healthy 39 for example the best babies zone initiative is a collaborative placebased effort to mobilize four sectorshealthcare early care and education economic development and community systemsto address the social determinants of health and improve birth outcomes 40 bbz works holistically to improve living conditions and opportunities for families by aligning resources building community leadership and transforming educational opportunities economic development and community systems in concentrated neighborhoods incorporating maternal and child health needs with planning a maternal and child health needs assessment geared towards the social determinates of health has much to offer to planners designing familyfriendly communities despite the planners stated goal of creating healthy communities and multiple tools planners have to address social determinants of health planning has not always distributed public goods well for children and parents families with children are sometimes viewed as a regional drain not generating sufficient tax revenue to offset the cost of the community services they demand 26 in 2008 the american planning association surveyed their membership with questions pertaining to planning familyfriendly cities results of the survey point to little awareness of services specific to families with young children for example slightly over half of participants explicitly referenced meeting families needs via their comprehensive plan and only 43 of respondents were aware of whether their community had an adequate supply of childcare and only 5 had a childcare plan 26 while scholarship connecting the pathways between structural and social determinants and health outcomes has blossomed planners may not be operationalizing these pathways to plan for environments supportive of maternal and child health one reason for the disconnect between planning practice and efforts to improve maternal and child health is the lack of knowledge within the planning profession of what within their professional purview influences maternal and child health to address this gap in planning knowledge we developed need indices that can be easily utilized by planners local governments and other stakeholders to evaluate and understand maternal and child health metrics in their region armed with this indicator data planners can then visualize which action items are within their scope of influence our multidisciplinary team developed several facets of the assessment that we feel assist in making this a planningfriendly needs assessment first we developed the indices at different geographic levels while countylevel need indices are helpful for planners who work for the state or county level zipcodelevel need indices may better facilitate local planners working at the municipal or community level second we utilized our skills as mch researchers and practitioners to gather existing scientific evidence on how multiple social determinants interactively affect mch outcomes and input them into the development of the need indices with this completed planners can understand and measure how their professional endeavors can improve mch without having to disentangle the complex connections between a large number of mchrelated metrics in addition to individual mch need scores on each metric we simplified the indicators into a composite need score for a whole domain these composite need scores provide planners with synthesized and straightforward knowledge on the overall status of maternal and child health outcomes and related factors for example if a county scored low in the community environment domain this is a sign that planners may have an outsized role to play in improving mch outcomes in that community third while most previous mch needs assessments focus on proximal health outcomes when selecting metrics to be included in the need indices we emphasized resourcebased indicators that reflect the economic and social contexts of communities where families live while healthcare providers and public health workers directly intervene on proximal health outcomes planners work in the public sector and use broad policy tools such as local laws plans standards public financing tools and other policies to manipulate social and physical environments that contribute to downstream health effects with the indicators in this needs assessment planners can act on the resourcebased indicators and intervene in the pathways from which social determinants affect health outcomes for example planners may help determine the location of new affordable housing construction bus line or grocery store which will in turn affect the resources available to individuals and their healthrelated behaviors fourth we used publicly available data for the majority of the indicators included in the need indices planners will be able to access the data from public sources without any cost and to update or filter the data to fit their customized need addressing the determinants of mch requires a multisector coalition the need indices presented in this work support efforts to identify and prioritize communities for strategic investment and programmatic supports across a range of domains that impact health the strong and growing empirical evidence of the role of structural communitylevel determinants of health is a call to action for disciplines who may be uniquely positioned to innovate and remedy longstanding health disparities operating above the influence of individual locus of control while planners are well positioned unpacking the factors contributing to a particular community need and designing and implementing programming to improve it will be most effective when undertaken in partnership with representation from public health health and government systems the need indices can support a wide variety of policymakers in comparing mch countylevel metrics across the state and prioritize communities for funding program administrators service providers local policymakers and advocacy groups can also use these local mch need indices to inform tailored programmatic and policy responses across multiple public sectors that benefit children and families our study has several limitations first there is no precedent for assigning weights on a large number of mch and sdoh indicators for creating composite need indices of local communities this study contributes a novel approach that calculates composite need indices as a weighted average of indicators the weighting scheme was informed by mch literature and is reflective of both data quality and content the scheme was designed through focus group discussion among a multidisciplinary team in the fields of maternal and child health epidemiology regional planning and state public health officials second we piloted the need indices in pennsylvania and our results may not be generalizable to other geographic areas however the majority of our indicators were derived using national data sources which make them readily applicable to other us areas conclusions an evergrowing body of evidence continues to stress the importance of addressing health outcomes through interdisciplinary approaches beyond the healthcare system addressing racism class discrimination and unsupportive policy environments for example a 2020 pediatrics article demonstrates the effect of government expenditures in housing parks and recreation public health solid waste management and other nonhealthcare expenditures on improving infant mortality 41 the emphasis on social and structural determinants of healthefforts required outside of the hospital and doctors officeoffers a clear invitation for fields like planning to utilize their skillset for improving community health from the planning perspective this invitation echoes the earliest motivations of the discipline a field historically concerned with reducing human suffering from rapid urbanization crowded living conditions polluted water lack of sanitation infrastructure and widespread disease 42 planners can and must revisit their earliest motivations and join in multidisciplinary partnerships to address preventable maternal and infant mortality we hope this contribution provides one such example for doing so by disentangling the complexities of the mch evidence base and tying it to resourcebased indicators we add a specific maternal focus to the literature and practice on planning familyfriendly communities supplementary materials the following are available online at supplementary 1 includes data year and pennsylvania statewide summary statistics for indicators included in the maternal and child health need indices supplementary 2 includes detailed description how the indicators were obtained and measured supplementary 3 presents how each indicators total assigned weight was calculated supplementary 4 presents the correlations between need indices of the 6 domains author contributions conceptualization xw jw kk sg dm td and mm methodology xw and mm software xw and jw validation kk sg dm td and mm formal analysis xw and jw investigation xw jw kk sg dm td and mm resources xw jw kk sg dm td and mm data curation xw and jw writingoriginal draft preparation xw and jw writingreview and editing jw and mm visualization xw and jw supervision mm project administration mm funding acquisition mm all authors have read and agreed to the published version of the manuscript

environmental and community context earliest in the life course have a profound effect on lifelong health outcomes yet standard needs assessments for maternal and child health mch programs often overlook the full range of influences affecting health inutero and early childhood to address this we developed a methodology for assessing community risk in mch based on six domains integrating 66 indicators across community environment socioeconomic indicators and mch outcomes we pilot this methodology in pennsylvania and share examples of how local governments planners and public health officials across the geographic spectrum can integrate this data into community planning for improved maternal and child health

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introduction the food and agricultural organization states that gender analysis seeks answers to fundamental questions such as who does or uses what how and why gender roles refer to behaviors learned by a person as appropriate to their gender determined by the prevailing cultural norms defined gender roles as socially constructed roles behaviors activities and attributes that a given society considers appropriate for men and women the debate continues as to what extent gender and gender roles are socially constructed and to what extent socially constructed may be considered synonymous with arbitrary or malleable ndukwu nwaru and okoye noted that gender has often been misunderstood as being about the promotion of women only but it focuses on the relationship between men and women their roles access to and control over resources division of labor and needs according to them men and women are affected differently in their operations by factors like markets and socioeconomic environments agriculture in nigeria is mainly practiced by all genders men and women are highly involved in the production and processing of crops and livestock although the nigerian constitution guarantees equal opportunities to both men and women in reality this is not so worldwide women face limited access to resources and are locked into relatively lowproductive work women in nigeria contribute immensely to agricultural production as they play a vital role in food production for the household family labor postharvest activities livestock husbandry as well as the processing and marketing of farm produce the livestock subsector in nigeria has been described as the most important economic sector in terms of rural employment food and nutritional security and the attraction of foreign direct investment lack of recognition of gender in agricultural development contributes to low productivity a higher level of poverty and undernutrition however ogunlela mukhtar and bag stated in their study that the role women play and their position in meeting the challenges of agricultural production and development are quite dominant and prominent their relevance and significance therefore cannot be overemphasized despite all the roles played by women in agriculture and other economic activities their contribution to the countrys development still remains largely undocumented and not utilized to eradicate poverty although the available literature shows that many studies have been done on poultry production the attention was more on the economic analysis of poultry farming some others looked at resource use efficiency in poultry production little or nothing has been done on the gender roles study as a factor in promoting poultry farming especially in kano state kuye et al noted that there is a need to design formulate and implement agricultural policies and programs that would remove gender disparity in land capacity building access to credit access to technology and access to relevant research results and extensions this study therefore provided a basis for government support for women towards training and financial empowerment to mainstream genderrelated issues in agriculture and rural development to stabilize their household economies increase overall profits and expand their poultry business by investigating the socioeconomic status of gender participation in poultry production in kano metropolis nigeria lga poultry active producers as of 2019 were identified and recorded the first stage involved the purposive selection of the entire active poultry producers in the kano metropolitan area namely kano municipal dala fagge nasarawa gwale tarauni kumbotso and ungogo local government areas of kano state the study followed the production scale classification of ajibefun and daramola which classified poultry farms with 50500 birds as small poultry farms 501100 birds as medium poultry farms and those farms that have 1001 to above birds as large farms this submission helps in measuring the production size of the poultry producers the second stage involved consideration of the total number of poultry producers from the eight metropolitan local government areas which generated a total of 272 classified into 194 males and 78 females but only 257 were reached during data collection and were used as the population of the study data for this study was collected mainly from primary sources primary data was collected with the aid of a structured questionnaire that was administered to the sampled poultry producers by the researcher which included socioeconomic characteristics such as gender age level of education marital status household size years of farming experience access to extension services level of gender participation and gender role in poultry production as well as the type of poultry extension services received by the poultry producers famers and constraints militating against poultry production methodology description of the study area analytical techniques the collected data were analyzed using descriptive statistics result and discussion socioeconomic characteristics of poultry producers in the study area the major occupation results of the producers was presented in table 1 the results show that about 369 and 235 of male and female poultry producers take trading as their major occupation while 201 of male and 206 of female poultry producers mostly engage in poultry farming as their main occupation respectively this implies that many of the male and female poultry producers have other businesses such as crop farming civil services and handcraft as their main occupation regarding their contact with extension agent table 2 indicated that 425 and 441 of male and female poultry producers have contacts with extension agents respectively while 575 and 559 of male and female poultry producers indicated that they have no contact with extension agents this indicated that the extension agents were not playing their role in promoting gender participation in poultry production in the study area poultry producers access to credit in table 1 also indicated that the majority of male poultry producers have access to credit while 151 of them have no access to credit it also indicated that most of the female poultry producers have access to credit while 167 of them have no access to credit implying limited access to credit by the poultry producers the results in table 1 for the marital status of poultry producers further indicated that 480 of male poultry producers were married while only 324 of the female poultry producers were married this portrays the fact that male married people dominate the poultry production in kano metropolis which makes it necessary for them to participate in economic activities as a means of catering to the needs of their families this corresponds with the findings of auwal et al and anarah et al in their gender participation study which showed that the majority of the poultry producers were married moreover table 1 results for the educational level of poultry producers showed that 168 of male poultry producers had tertiary education as compared to 132 of female poultry producer who had tertiary education and 132 and 55 of males had primary and secondary education respectively while 235 and 294 of females had primary and secondary education respectively it is indicated that 223 of males and 280 of females have informal or islamic school education only while 56 of males and 59 of female poultry producers have never been to scho ol also substantial numbers of male poultry producers attended tertiary institutions this result clearly revealed that male poultry producers were more opportune to source and access written and formal innovation for the betterment of their poultry enterprises there will be more improvements in their production compared to 132 of the female gender that attended tertiary institutions the results in table 2 show that almost half of the male poultry producers fall within the age bracket of 3240 years while more than half of the female poultry producers fall within the age brackets of 3140 years those who belong to the age group of 51 years and above are few for both male and female poultry producers this indicates that more youth are into poultry production than any other category of people table 6 showed that 335 of males and 294 of females poultry producers had 1721 persons as their household sizes while 263 and 264 had 711 households it is also indicated that 201 of male and 206 of female had 1216 persons as their household size while 162 of both male and female poultry producers had 26 persons in their household this finding showed that both male and female poultry producers had a large dependable number of household sizes that may serve as a source of labor in their production activities this is in line with vihi kwembeb and jesse who reported that the majority of male and female producers had household size of 610 persons table 6 further indicated that of male and of female poultry producers had production experience of 1120 years while of male and of female poultry producers had production experience of 2130 years and 257 of male poultry producers had 210 years of experience in production compared to female poultry producers who also had 210 years of experience in production it also showed that 123 of males and 117 of females had 31 years or more of experience in production the indication is that the majority of the poultry producers had 1120 years of experience it suggests that most of the poultry producers have accumulated enough skills and knowledge in poultry production that can help them boost their production as well as adapt to good management practices this result agreed with the findings of oni nkonya pender phillips and kato who reported in their study that most experienced producers tend to invest their resources and incomes towards increasing their level of participation in arable crop production experience can be seen to improve poultry productivity as a result of skills knowledge and practice acquired over the years 3 presents gender participation in poultry production activities the result shows that female poultry producers participated in all the poultry management activities however they participated mostly in feeding sanitation medication and water management on the other hand their male counterparts similarly participate in all the activities but most of them engage in house construction medication sanitation and feeding meanwhile the least participating activities were marketing and brooding among male poultry brooders while debeaking and marketing are the least of the poultry management activities participated by females in the study area the result implies that both genders participated in the poultry management activities in the studied location 4 presents the flock size of the poultry producers the result shows that 274 of male and 279 of female producers have between 1 and 500 birds while 279 of male and female producers have between 501 and 1000 birds table 4 also indicated that 251 of males and 250 of females have between 1001 and 1500 birds while 196 of males and 191 of females have 1500 birds and above the mean flock size for men is 1023 while that of women is 980 this indicates that there is no gender dichotomy in terms of the production scale of poultry in the study area this finding contradicts what was opined by mitchell that men participate in livestock production more than women due to access to capital types of poultry reared table 5 reveals that almost and third of male producers and female producers respectively rear layers while both 279 of males and 280 of females rear cockerel it also shows that of male poultry producers rear local compared to their female counterparts who also rear local table 5 also depicts that 179 of male poultry producers and 176 of female poultry producers rear broilers this finding revealed no difference in terms of the type of poultry reared by both genders system of poultry production table 6 indicates the results for the system of poultry production in the study area results show that the majority of male and female producers use the intensive system of livestock production while 324 of male and 279 of female poultry producers use the extensive system in their poultry production the reasons for the extensive method as revealed by the farms were due to fact that the cost of feed and the rearing of local poultry significantly contribute to higher participation in the extensive method of poultry production while the layer production conducted by the respondent prompts the intensive method of poultry production constraints faced by gender in poultry production the result in table 8 indicated the problems that hinder womens participation in poultry farming table 8 indicates that insufficient funds or inadequate capital is the major constraints that mitigates the loss of poultry production for women producers the result also indicated that 72 of the female producers are held up by domestic and household chores which reduces their participation in poultry production the result also depicts that cultural and religious beliefs are the third constraint that limit womens participation in poultry production it is shown in the table above that cultural beliefs say that women are not supposed to participate in any economic activities but rather that they are the primary caretakers of children table 8 also shows that poor management of poultry birds due to house chores and other responsibilities as well as a high cost of feed are faced by 529 of poultry producers as a contributing constraint to lower participation in poultry production the result also indicated that inadequate veterinary services faced by the women limit their participation in the enterprise conclusion and recommendation poultry production is dominated by male poultry producers and the producers mostly practice intensive systems of poultry production in the study area both genders actively engage in the feeding sanitation and medication of their poultry birds in the study area however findings revealed female poultry producers to have inadequate access to credit facilities and veterinary and extension services thereby limiting farming participation in the study area insufficient funds household chaos sociocultural and traditional beliefs and the high cost of feed are also among the constraints posing a threat to female participation in poultry production in the study area the following recommendations were made based on the findings of this study i there is a general low level of female participation in poultry production in the study area therefore the government should design formulate and implement genderunbiased agricultural policies and programs that would remove gender disparity in land capacity building technology extension and guarantee equal opportunities to both men and women particularly in decisionmaking access to and control over resources political position and other socioeconomic opportunities ii the study also found that more than half of both male and female producers had no contact with veterinary extension agents and only a few producers received veterinary services this indicated inadequate extension and veterinary services which limits promoting gender participation in the study area therefore there is a need for more extension agents in the study area iii the study also established that insufficient funds domestic and household chores and cultural and religious beliefs are the main constraints that limit gender participation especially for female producers in the study area therefore the government needs to provide funds and create religious awareness through religious leaders to encourage woman to participate in poultry production references

poultry production plays a vital role in the socioeconomic development of kano metropolis nigeria providing employment opportunities enhancing household income and ensuring food security despite the significant contributions of the poultry industry womens participation in this sector remains constrained by various socioeconomic factors this study aims to investigate the socioeconomic status of gender participation in poultry production in kano metropolis nigeria the study employs a quantitative data collection technique a structured questionnaire was administered to 257 randomly selected poultry producers including both men and women to gather quantitative data on their socioeconomic characteristics production activities scale size types of poultry reared production system and constraints faced the study findings revealed only few 30 of the poultry producers are females males 480 and 324 of female poultry producers are married also 307 of males and 132 of female poultry producers had tertiary education in addition most of the males 475 and females 574 are within age range of 3140 years similarly male 369 and 235 of female poultry producers mainly engaged in trading as their main occupation however male 352 and female 352 poultry producers had flock size of 50500 birds moreover only few males 425 and females 441 poultry producers have contact with veterinary extension agents regarding poultry management activities participation female producers were found to participate mostly in feeding 436 sanitation 416 medication 294 and water management 279 on other hand their male counterpart mostly participated in house construction 391 medication 408 sanitation 363 and feeding 307 findings also show majority of males 676 and female 721 poultry producers use intensive system of livestock production in the study area the result findings also reveals insufficient fund 853 and domestic and household work 721 as the major constraints posing threats to womenfemale participation in poultry production the study concluded that poultry production is dominated by malemen and therefore recommended that there is need to organize programs that will include more woman in poultry production

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global public health research among transgender transsexual populations has almost exclusively focused on hivaids because trans women have been described in public health literature as more vulnerable to engaging in risk behaviour for hiv infection research and funding have focused primarily on addressing this concern in puerto rico most studies on the trans community have similarly focused on the impact of hiv on trans women and factors influencing their vulnerability the focus on hiv among trans women has come at a cost to trans men who are often neglected in research on trans communities partly due to their presumed low prevalence resulting in a lack of research on the social context of health and illness among trans men examining the embodied experiences of gender and sexuality among trans men is critical to understand the health disparities this community faces the objective of this article is to document identity constructions of trans men and buchas in pr and to critically examine the effects these constructions have in their bodily practices and health we will explore how these categories are manifested and identify some healthrelated needs and vulnerabilities they face cultural context of puerto rican trans men and buchas pr is the smallest of the greater antilles in the caribbean characterized by strong cultural adherence to traditional gender roles including machismo and marianismo one of the consequences of the social value placed on these models is a high degree of intolerance for gender nonnormativity such intolerance results in stigma and discrimination heightened vulnerability to hiv lack of social support reduced access to health care services unemployment and poverty the transgender concept has been often described as a macrolevel category that encompasses a wide range of gender presentations and identifications that are culturally variable in pr the population of trans men has remained largely hidden within the lesbian community which has itself been described in latin america as invisible given the lack of information and resources trans men and buchas have found social support in a community that shares some of their struggles but does not represent their particular realities or needs in pr the term bucha derives some of its social meanings from the english term butch which refers to a woman who assumes social roles typically attributed to cisgender males i locally trans women have been studied more extensively and there is a gap in knowledge of trans men it was not until 1990s that the presence of gender transgressive identities became evident in local vernacular studies regarding the lesbian community have been mainly approached from a feminist perspective and presented in the form of poetry or literature configurations of the i cisgender is a term often used in social science literature to denote an individual whose selfidentity conforms to the gender that is socially assigned to himher at birth based on biological sex the term is useful in that it decenters normative gender constructs that might otherwise be essentialized as simply natural bucha identity in pr have been studied largely from the perspective of migration certain strands of puerto rican culture undergird intolerance towards diverse sexual orientations and gender identities resulting in migration of gender nonconforming people to the united states migrations have played a role in the configuration of nonnormative sexual and gender identities but there is still much descriptive ethnographic research to be done to understand their transformations trans people face major barriers to employment nondiscrimination public accommodations and general social acceptance however vulnerabilities of trans men have been largely overlooked ii emphasis on trans women prevents the development of a fuller understanding of needs and appropriate public health initiatives for trans men the lack of attention granted to trans men has contributed to a slower diffusion of transgender terminology and selfidentification in pr prior research on hiv has been shown to shape identification practices of sexual minorities which social science researchers have described as the medicalization of sexuality and sexual terminology trans men have been largely ignored in hivaids research and intervention and this has contributed to their relative invisibility in public discourse and health initiatives border wars intersections and distinctions between trans and bucha categories there is an ongoing debate in the scientific literature regarding differences and similarities between trans men and butch lesbians halberstam and hale have described the semantic tensions between these gender categories as border wars the debate is in part due to the overlap of identity constructions and social characteristics between both crawley states that trans and butch categories are similar in their gender presentation and ambivalence towards the feminine body but markedly differ in their gender identification trans men often selfidentify as men and butch lesbians as women halberstam stresses that trans men are associated with a desire for reembodiment while butch women are associated with a playful desire for masculinity and gender deviance in pr a distinction between categories is far from clear with much overlap and inconsistency in selfdefinitions of gender these finegrained distinctions between the puerto rican cultural context and those described in other settings are critical in addressing health vulnerabilities and gaps in public health services ii the literature on trans men has been more extensive in the social sciences than it has in the health sciences anthropology cultural studies and the humanities have contributed to a growing crosscultural literature on trans men and butch lesbians in recent years health related issues in the trans and butch community in pr in pr the absence of social research on trans men and buchas health is related to lack of theoretical conceptualizations of health and illness health as a social process with biological implications has been conceptualized as a system of classification that assigns specific labels to individuals sickhealthy normaldeviant and male female are just a few examples of binary pairs used through medical and health discourses to redistribute individual variability into bipolar categories once individuals fall outside the confines of normative healthy categories medical and health discourses have difficulties with categorization an essential step in identifying health problems and establishing treatment plans or guidelines such categorization of individuals and their embodiment of disease or deviance is an integral part of social regulation of marginalized communities and maintenance of bipolar gender categories that these groups challenge through their embodied practices social stigma is a common response from the medical and health establishment when faced with people who transgress such categorizations medical institutions are often sites that exclude or delegitimize trans bodies and identities and their unique clinical needs too often health care services and health promotion campaigns contribute to trans invisibility and marginality with adverse health consequences for them a wide range of health conditions associated with stigma and discrimination disproportionately affect trans populations including substance abuse mental health conditions and cancer lack of preventive care and the delay of urgently needed care constitute major health risks for trans men and butch lesbians this is due in part to fear of being discriminated against misunderstood or stigmatized by health professionals moreover because trans men and butch lesbians have remained understudied there is lack of information regarding incidence of chronic health conditions such as cancer or strategies to address them these realities have created a gap between the needs and access to social and health related services and require competent professionals who understand identity constructions and factors related to health in the community of trans men and buchas pr is perhaps an extreme case of such gaps in services and knowledge method we conducted a qualitative exploratory study using different methodological approaches implemented sequentially in three phases ethnographic observations focus groups and individual semistructured indepth interviews the study protocol was reviewed and approved by the institutional review board of our institution all participants were recruited by convenience using snowball sampling from key contacts identified through ethnographic observations in social settings frequented by the population including a popular lesbian night club in san juan key gathering point for trans men and buchas total sample consisted of 29 participants who selfidentified as hombres trans or buchas inclusion criteria were being at least 21 years of age and selfidentifying as a trans man or bucha inclusion of both trans men and buchas was informed by initial ethnographic observations and key informant interviews that revealed that in pr the border between these categories is extremely fluid and permeable we sought to understand how individuals moved between and among these identities as it can be seen in table 1 participants used a wide array of labels to describe their gender categorization we discuss subtle distinctions between these terms but they cannot be presumed to be absolute or stable ours is an exploratory study aimed at documenting nuances and describing shades of gray in our sample as a starting point to research on this population ethnographic procedures we conducted ethnographic observations during three months in bars and pubs located in the metropolitan area of san juan frequented by trans men and buchas observations and informal interactions were critical to examine the social and structural factors underlying daily life and identity constructions and healthrelated practices in this population observation involves a structured manner of immersion in local cultural worlds in order to learn about what people do and what it means to them while also attending to ways in which contextual factors shape and constrain individual and group practices during ethnographic outings led by the first author with participation of coauthors we engaged in informal interactions with owners employees of establishments and members of the community of trans men and buchas to gain access to the community a trans woman who worked as a consultant in another research project introduced us to key gatekeepers of the lesbiantrans men bar scene where most observations were conducted gatekeepers or key informants demonstrated genuine interest in our research they linked our team to key contacts in the community and collaborated with referral of eligible participants through frequent and active participation in social and community activities at this key site we gained trust with potential participants in focus groups who became interested in the study and informed their peers focus groups and interviews were conducted in spanish data collection involved writing ethnographic field notes and analytic memos and development of provisional hypotheses based on observations further explored in subsequent fieldwork toward the beginning of the ethnographic phase we developed an ethnographic guide to systematize subsequent observations and reflect on the effects of various social and structural factors on health behaviours and practices the guide focused on issues regarding gender identity constructions the meanings of community and social affiliation and tensions or variations in gender representation and performance focus groups we carried out two focus groups composed of trans men and buchas to gather detailed information about topics that have been less explored or might benefit from collective analysis this strategy allowed our team to evaluate shared views regarding a range of topics related to identity construction and health we recruited 20 participants inclusion criteria were being at least 21 years of age selfidentifying as a trans man or bucha and providing verbal consent given that this was an exploratory study and that our preliminary research suggested no clear distinction between buchas and trans men both were integrated into our focus groups nevertheless we diversify the sample by recruiting ten participants who identified primarily as bucha and ten as trans men we used a focus group guide to lead discussion of relevant topics the guide included questions on 1 gender identity 2 meanings of the words bucha and trans men 3 bodily modification practices 4 experiences of stigma and discrimination and 5 exploration of healthrelated needs focus groups were conducted in the bars facilities prior to its opening discussions were audio recorded for transcription and analysis individual indepth interviews in the final phase we conducted individual semistructured indepth interviews with 9 participants to gather additional narrative on experiences related to their social lives and health vulnerabilities in a oneonone encounter we selected participants during fieldwork or by referral selection criteria were the same used for focus groups we used an indepth interview guide to provide uniformity and to guide conversations while allowing flexibility based on contents addressed by participants the guide included questions on 1 identity perception 2 bodily transformations 3 health issues 4 work related experiences 5 experiences in affective relationships and 6 general experiences with society we included a demographic data questionnaire with questions addressing economic status gender identification area of residence educational level and sexual orientation among other variables confidential interviews lasting 6075 minutes were conducted in private locations we provided a monetary incentive of 25 data analysis audio files were transcribed verbatim into wordprocessing files data obtained were coded and organized using a codebook developed from a grounded analytic reading of transcripts to identify a core set of issues and interrelated themes we coded the data using critical discourse analysis to focus on relations between discourse power dominance social inequality and the position of the researcher in social relationships since we collected and analysed data in spanish we translated relevant narratives to english for publication purposes we made an effort to capture the exact message and included some words in spanish that we considered had no equal translation to english results to facilitate the analysis of narratives we will begin by presenting an ethnographic fieldnote excerpt in order to illustrate the lack or partial incorporation of the category hombre trans in this population our analysis focuses on two main domains or processes that reflect the intersection and social context of gender identities and the health of trans men and buchas these were 1 bodily representations and gender performance and 2 the meanings of female biological processes we identified each narrative with the participants selfidentified gender category to illustrate the diversity of concepts used to describe their gender identities ethnographic fieldnote excerpt the following ethnographic field note describes an interaction between the research team a key informant of another study that is a trans woman and two participants this vignette is helpful in situating our analysis within the categorical ambiguity between trans men and buchas it exemplifies the incomplete or inconsistent integration of trans identity in this community we started the night at a local bar frequented by the community of lesbian women once we got there we noticed that the topic of conversation we were interested in exploring had already started owners of the bar laura and milagros 1 a couple who identified themselves as femmes welcomed us and the first thing they told us was that we had arrived at the appropriate moment they were talking with two costumers sandro and leon who selfidentified as buchas about the roles of lesbian women in their relationships while they identified as buchas they used masculine pronouns to refer to themselves sandro and leon mentioned that two femmes together was a transgression of what is expected for a lesbian couple for them it was essential that a couple included a bucha or that one of the parties assumed the male role laura and milagros disagreed leon who was more vehement in his opinion that lesbian couples should follow heteronormative gender rolestold us that while two femmes together was acceptable a couple composed of two buchas was not to sustain his viewpoint he told us a story about a time another bucha asked to go to the bathroom with him and that this had disgusted him teresa a trans woman and key informant asked sandro and leon if they defined themselves as trans men the answer was we are buchas teresa continued to explain the meaning of the trans concept according to her and why she thought that sandro and leon were actually trans men leon clarified that he was a man here and wherever i go i am attracted to very feminine women he explained leon provided the following explanation to teresa of what it meant to him to be a bucha he asked teresa you are a man right to which teresa replied no and leon continued you have a dick down there but you see yourself as a woman… well for me is the same but the other way around… this fragment of the ethnographic field note illustrates a common mixture of different notions of gender that are highly fluid and with blurred boundaries a phenomenon regularly documented in our field notes the concept of trans men is not clearly integrated into everyday discourse in the community leading many participants to identify as bucha but describe themselves as men while bucha is generally used to refer to a femalebodied lesbian woman who exhibits a masculine gender performance we found a regular discursive slippage between this category and a more reified notion of being a man in the above field note sandro denies his identity as a trans man by simply excluding the prefix trans and sees no inconsistency between being a bucha and being a man another participant changed the gender of the word bucha to bucho in order to better described what he felt he was once again he avoided using the term trans when we asked if he defined himself as trans he stated that he did not know the definition of the term but added that he was a man trapped in a womans body all participants manifested a desire to modify their bodies to be more aligned with a masculine sense of self which is often described as definitional of transgender identity in the scientific literature in pr bucha is a broader category that encompasses many of the meanings associated with trans identity in the near absence of a distinct label to refer to trans men while three of our interview participants selfidentified as trans the majority did not use these labels and many were unsure of its meaning interestingly the category of trans woman is recognized and generally understood whereas trans man is a nascent social category that is rarely used in social practice perhaps because of the broad subcultural definition of bucha which subsumes many characteristics associated with trans while this phenomenon needs further study we believe it may have important implications for policies programs and interventions particularly regarding the prominence of the local category bucha west and zimmerman describe doing gender as the interactional process of performing gender identities that reaffirm culturally defined notions of the masculinefeminine binary even as they may seek to overcome or resist them the following quote from one of our participants selfidentified as a trans man illustrates how gender identification was described by many of our participants incorporating a gender binary through which ones own marginal gender identity was experienced or reworked im going to describe what i think i am… i feel that i have a masculine mind inside of a feminine body with feminine sensitivity and the hardness that is needed in order to survive maybe if i was completely feminine id still be living with my mother hide under her skirt because maybe i would be afraid of life to confront things or i would have been able to empathize more with who she was that is submissive… participant selfidentified as trans this participant attributed characteristics such as weakness to a feminine role while exalting male attributes presumably needed in order to survive several participants similarly appropriated bipolar notions of gender into their descriptions of selfidentity as illustrated by several participants who described their gender identities in relation to their role as household provider you start to feel like the strongest person in the relationship because you are the one that has more responsibility at least in my case im the one with the most responsibility my house lacks nothing… i dress like this and im the strong part of the relationship participant selfidentified as bucha …you try to assimilate all you can from manhood at least in my case thats what i do and in my house its like that im the one that provides and the one that says how things are… participant selfidentified as trans man bodily presentation as a masculine individual was extremely important for trans men and buchas our participants shared a wealth of intimate information regarding their bodily practices for physical and gender performance and their techniques for projecting a masculine identity bodily representation and gender performance at 23 i started to change completely i changed the way i dressed but then i have never gone shopping for male clothing i cut my hair shorter and started to transition participant selfidentified as trans man when i was in high school i stole my cousins swimsuits… i stole them and wore them and my mother preferred to buy me some male pants to avoid having to steal from my cousin participant selfidentified as bucha i hated to dress like a girl… wearing dresses and high heals… i was a tomboy teenager since i was little i dressed as a boy and i used to buy male clothing… nowadays i buy pants in womens department stores because they fit me but i prefer to buy in the mens area i also wear male underwear participant selfidentified as a fluid identity several participants described biomedical technologies or procedures for body modification in which they had engaged such as testosterone supplementation binding of the breasts and penile prostheses to embody a more masculine social role in many instances the use of these technologies represented significant challenges for daily life and activities in most cases participants had gone through long periods struggling alone and in silence to align their bodies with their gender and lacked safe spaces to obtain accurate information about practices and technologies that might be available to them these practices are entirely invisible in health care settings and public health programs in pr the social context of use of biomedical technologies such as testosterone supplementation was nearly impossible for our participants to discuss with health care providers which strongly constrained their access to appropriate treatment and public health services the meanings of female biological processes the physical body might be described as a signifier that tells others what to expect in terms of social roles for who is challenging dominant symbols of gender and sexuality the body betrays or ruptures gender expectations and becomes a site for social conflict stigmatization and stress during puberty mindbody dissonance becomes more evident as the symbol of the body more intensely contrasts with an underlying sense of ones gender identity a study conducted by devor found that most trans participants mentioned not being able to cope with the physical changes they observed during adolescence some participants expressed the same feeling of being betrayed by the body during puberty before puberty i used to wear a pony tail and i had really long hair and i put it up in a pony tail and pretended i was a boy you know what i used to pray to god please that tomorrow i wake up as a boy its really like depressing but then i say to myself well maybe i will never get my period maybe my body has a physical problem and thats why i feel this way but when i got my period all my hopes went away… participant selfidentified as trans men for me it was something that i was embarrassed of my own body i couldnt assimilate i mean that my breast began to show that i was developing a womans body i couldnt… sometimes i would lock myself up in my room and cry and say why god if you know i like women why this god i said why i was born like this like a woman i feel like a man and im chained to a womans body participant selfidentified as bucha and man an important implication of the rejection that these individuals felt towards female anatomy was their attitude toward gynaecological exams and followups trans men and butch lesbians visit the gynaecologist less frequently for pap spears and preventive care which is potentially linked to higher risks for cervical and uterine cancers one of the reasons for this is the denial of the female body as an expression of gender ambivalence or dissonance i say why go to the gynaecologist if im a man and i have confidence in myself im a man you know my body is a carapace… i dont have to why let anybody see my body participant selfidentified as bucha and man another reason for avoiding gynaecological exams was related to discomfort participants experience with their genitals and the pain that accompanies the examination to have those pap spear exams is for me very stressful…i have had it two times the first one was uncomfortable but i dealt with it it did not hurt but this time it was horrible it was very painful i dont know why it hurt so much and i dont know if it was the tension that i had for trying to avoid it i want to have a hysterectomy to avoid doing it all because i dont want to go through that again participant selfidentified as trans man such experiences of being probed in areas of the body that provoked shame and bodily dissonance contributed to a pervasive sense that health care facilities are menacing spaces the lack of clinics specializing in trans health in pr functioned as a significant barrier to accessing basic preventative care and quality treatment as participants simply did not see the available clinical services open to noncisgender individuals no i cant go to the clinic because theres a bunch of women waiting at the gynaecologist office and i cant like be sitting there waiting to be called i couldnt… and finding a gynaecologist that can work with you because you know its not the same people look at you… unless i had gone with a family member and pretended that it the appointment was for her but then when they called my name… so no i couldnt go participant selfidentified as trans men even when participants have strategies such as seeking the company of a family member they do not feel safe most of our participants only sought health care during emergency situations one of them acknowledged that he did not seek preventive care regularly and attributed it to lack of guidance on that matter i had never seen the gynaecologist but my insurance was going to expire… so i went and they discovered that i had something that needed surgery now i have to go because of the surgery but i had not gone before… youre right we dont go regularly to the gynaecologist… nobody talks about it nobody brings this up anywhere participant selfidentify as bucha noncisgender constructions were directly linked to problems accessing health care participants faced difficulties in understanding how specific health care services intended for cisgender females were still applicable to trans men and buchas who had female genitalia but masculine gender identities clinics and hospitals became sites for uncomfortable embarrassing or oppressive social interactions that functioned to stigmatize undermine or delegitimize their expressions of self individuals who challenge binary notions of gender might face difficulties in accessing services or even understanding the need to access routine health and prevention services that they do not associate with their own bodies or identities this makes it very unlikely that public health policies and programs particularly those related to reproductive and sexual health to reach trans men and buchas who would not see themselves as target of programs designed for cisgender women conclusions and recommendations this study the first to our knowledge focused on trans men and buchas in pr represents an initial step in understanding the social context of this invisible community and implications of their experiences for health and wellbeing first our participants described gender identities in their communities using local butchfemme categories in which the masculine figure the bucha expressed an embodied notion of masculinity that incorporated a variety of practices and bodily technologies some of these practices involved nonclinical use of testosterone for body modification analogous to informal hormone injections that have been described for trans women that may contribute to other health risks particularly when needles are shared others described the use of penile prostheses and chest binding experiencing discomfort and challenges with these practices bucha is a broad subcultural category that is often associated with bodily dissonance and identifications that are akin to most definitions of transgender or transsexual in the global scholarly literature while trans terminology exists in pr bucha is a dominant cultural category that is inclusive of those who identify themselves as men and engage in body modification practices and technologies the appropriation of heteronormative models for organizing gender relations and the importance of such models for legitimating masculine identities need to be considered in the development of psychological clinical or public health initiatives to reach this community clinical and public health services for trans men and buchas need to include training for personnel on the meanings of these terms and the bodily ambivalence or dissonance that commonly accompany them such training should require adaptation to local context and terminology subcultural realities of trans men and buchas are likely to be misunderstood and stigmatized by health care providers this would contribute to avoidance of health care and underlines the importance of developing interventions aimed at promoting preventive care for this population stigma reduction interventions and antidiscrimination policies for trans men and buchas should be implemented across the health care system even as more transspecific services are developed participants told many stories of being highly uncomfortable of having their bodies inspected by medical personnel particularly during gynaecological exams bodily ambivalence or dissonance generated strong resistance to health care facilities described as menacing places or sites where they did not belong it was difficult for them to understand why health care services for cisgender females were necessary for buchas and trans men partly due to a tendency to invoke strong contrasts between cisgender women and buchas creating reified notions of differently gendered bodies in this context it may be more difficult for trans men and buchas to understand how or whether clinical and public health recommendations for cisgender women are applicable to themselves future initiatives oriented toward this community should incorporate subcultural knowledge inclusive of trans men and buchas to adapt current interventions and outreach programs and to create safe spaces where gender nonconformity is welcomed and explored openly we believe our findings underscore the urgent need for transoriented health care and public health programs in pr

public health research among transgender populations globally has primarily focused on hiv aids however trans men remain outside of this conceptual framework with distinct but overlapping social contexts and needs in puerto rico pr the trans men population has remained largely hidden within the butch lesbian community the objective of this article is to document the identity construction of trans men and buchas local term to refer to butch lesbians in pr and its relation to their bodily practices and overall health we conducted an exploratory qualitative study with 29 trans men and buchas based on ethnographic observation focus groups audiorecorded indepth interviews and critical discourse analysis findings emphasize two domains to be addressed by health policies and initiatives 1 bodily representations and gender performance and 2 the meanings of female biological processes this smallscale ethnographic study represents an initial step toward understanding the social context of this invisible community and significant implications for their health and wellbeing we provide several recommendations to address public health concerns of this understudied marginalized community

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background the illicit use of drugs for recreational purposes or for eliciting intoxicating effects has been recognised to be a growing and burdensome public health issue particularly among young adults in highincome countries 1 2 3 and recently in developing countries 4 5 6 7 the global deaths caused directly by the use of illicit drugs have increased by 60 from 105000 deaths in the year 2000 to 168000 deaths in 2018 8 the adverse effects of drug abuse include noncommunicable diseases cardiovascular and central nervous system collapse 9 addiction 10 mental health issues 1112 accidents 13 involvement in criminal activity 14 and risky sexual behaviours 1516 also mental health disorder among youths aged 1024 which accounts for about 2 of global deaths has been linked to illicit drug use 17 cannabis use can affect school performance 18 especially in mathematics heavy and regular marijuana use during teenage years can result in an 8point reduction in intelligence quotient 19 according to the united nations office on drugs and crime nigeria is one of the current highest consumer of cannabis and amphetamine in africa 8 nevertheless studies on recreation drug use in nigeria are scarce and exitsing studies have focused on high school students and mostly on the use of alcohol also most of the studies focus on the role of individuallevel factors and peer influence there is however a paucity of studies examining the influence of familyhouseholdlevel and social factors on recreational drug use among adolescents and young adults in nigeria our study fills this gap by examining the drug use prevalence and frequency as well as the role of familyhouseholdlevel and social factors on recreational drug use among adolescents and young adults theoretical underpinning we drew from the socioecological model 20 to understand the role of familyhouseholdlevel and social factors on recreational drug use among adolescents young adults the sem has proven to be an instrumental theoretical framework for addressing several youth development outcomes the sem posits that youth behaviours are not influenced only by their individual characteristics but by other factors in their environment which could be at the family school peer community and national level this model assumes that interactions between youth and different levels are mutual as they both influence each other the socioecological model postulates that the family is a childs early microsystem for learning how to live and about the real world the influence of the family is strong in the life of a child it provides the nurturing centrepiece for the child one mechanism through which the family influences young peoples drug use may be through living arrangements and parental monitoring the age of adolescence is a transition phase and the presence of parents leaves a permanent influence that is crucial for the development of youth the family instils norms and values in a child through constant training control and monitoring which is also dependent on the household living arrangement the family norms and values instilled from childhood to adolescence period will continue to influence the behaviour of young people even until their adulthood there is evidence that youths with a higher level of parental monitoring have lower odds for risky behaviours 21 based on sem family structure living arrangement and family support could influence young peoples use of drugs a study has shown that higher parental education and income are associated with marijuana use in the united states 22 we therefore posit that adequate family support will be associated with reduced odds of recreational drug use among adolescent and young adults in nigeria living in ones parent household may influence the amount of time spent with the child and may also influence closeness to the child that may continue even when the youth leaves the home individuals who did not live with their parents due to deaths or divorce may have missed out on some of the critical parental lessons capable of shaping their later life behaviours the effect of living in the same household as ones parent on drug use has never been investigated in the nigerian context our study proposed that living in the same household as ones parent will reduce the odds of drug use among young people even when they are in universities religion is also a microsystem factor that could impact illicit drug use among adolescents and young adults religion teaches codes of ethical behaviours and forbids the use of illicit drugs as such we posit that frequent attendance of religious fellowships will be associated with a lower likelihood of illicit drug use among young nigerian adults in nigeria the socioecological model also illustrates the impact of meso exo and macrosystems on the development of a child however our focus in this study is limited to the impact of microsystem factors such as the family and religion in understanding young peoples illicit drug use methods study design the data analysed in this study came from a more extensive study which assessed the sexual health of university students in nigeria full details of the methodology have been published elsewhere 23 24 25 this descriptive crosssectional study was conducted among male and female university students in two nigerian universities between february and april 2018 the two universities one owned by the state government and the other owned by the federal government were selected purposively a selfdesigned questionnaire was administered to 800 consenting male and female students through facetoface interviews a pilot study was conducted among 20 demographically matched students in another university and feedback was obtained to improve the questionnaire experienced research assistants who were trained purposively for this study conducted the interviews participants and sampling the study participants were male and female students of the two selected universities the population of students in both universities was about 45000 participants were selected using stratified random sampling stratification was based on sex level of study and course of study only undergraduate students were included in the study for representativeness the estimated sample size was 384 students per university this was determined using the sample size calculator at a 95 confidence level ±5 margin of error however 400 students were selected per university after adjusting for possible incomplete responses overall 800 male and female students took part in the study however only 784 questionnaires were returned with complete responses ethical statement all participants provided written consent and the rights of participants to privacy anonymity and confidentiality were maintained throughout the study the university of fort hare and dependent variables the main outcome variable was a twocategory nominal measure of recreational drug use participants were asked have you ever used substancesdrugs like codeine marijuana tramadol for pleasure or to ease tensionstress to estimate the recent use of drugs for recreation we asked participants do you currently use substancesdrugs like codeine marijuana tramadol for pleasure or to ease tensionstress to understand the frequency of recreational drug use we asked participants to state the number of days they have used recreational drugs in the past 30 days we did not ask questions on specific drugs which has been noted as a limitation of this study independent variables our variable selection was informed by the sem 20 we included individuallevel characteristics such as age and gender age was measured by asking participants to indicate their age at their last birthday we later categorised these ages into a categorical variable for bivariate and multivariable analyses also participants were asked to indicate their gender based on the sem propositions familyhousehold factors are important microsystem predictors of health outcomes 20 we included several family factors such as family structure family support death of parents and living with parents in this study family structure was measured by asking participants to describe their family type we provided four categories for participants to choose from which include nuclear family singleparent family polygamous family and foster family family support was measured by asking participants to rate the level of support they receive from their parents responses were categorised as adequate support moderate support insufficient support and no support our operationalisation of family support substituted for family wealth we note that it is perhaps not only the amount of money a child receives from home that matters but also how the child perceived the money to be sufficient to meet their needs or not as such we asked participants to consider the support they get from their family in totality that is including support beyond money also we used the term family support loosely given that some students were orphans thus they could reference the support they received from their guardians as family support financial support is important for students given that a majority of them depend heavily on their parents for university tuition fee and other living expenses thus the lack of financial support means that students feel unsupported however it is important to note that in rare cases parents could provide adequate financial support but less emotional support overall our question is mostly an indication of how participants perceived the level of support they receive from their parents rather than a measure of monetary value perceived parental support is an indication of the value students attribute to the support they receive from their parents we also asked participants whether their parents are alive and if they live with their parents when not in school responses were a binary choice of yes or no another microsystem factor we considered in this study that could potentially influence young peoples drug use for recreational drug use is religion we asked participants to indicate their religion from a list containing the main religious groups in nigeria participants religious affiliation was classified as christianorthodox christianpentecostal and muslim we further asked participants about their frequency of attendance of religious fellowships we provide five options which include every day twice a week once a week once a month and once a year we classified those who attended religious gatherings every day and at least twice a week as frequent attendants those who attended once a week as moderate attendants and those who attended once a month or in a year as low attendants statistical analysis the data generated through the questionnaires were coded and captured into the statistical package for the social sciences data were cleaned for possible data entry errors descriptive statistics were used to summarise all variables of interest frequency counts and percentages were computed mean median and standard deviation were calculated for continuous variables unadjusted binary logistic regression model was used to examine the effect of each individual level factors familyhosuehold factors and religion on having ever used drugs and current use of drugs for recreational purposes adjusted binary logistic regression model was used to examine the predictors of drug use among the students 95 confidence intervals were estimated for each odds ratio all pvalues less than 005 were considered statistically significant results the median age of study participants was 22 years the demographic characteristics of the study participants are presented in table 1 most participants were aged 24 years and below resided off campus from a nuclear family and received adequate support from home recreational drug use about a quarter of the students had ever used substancesdrugs like codeine marijuana and tramadol for recreational purposes and the proportion varied by age sex and family support the results of the unadjusted and adjusted logistic regression are presented in table 2 in the unadjusted logistic regression model sex age living with the father mother alive living with the mother family structure family support religious affiliation and higher frequency of religious attendance were significantly associated with having ever used drugs for recreational purpose in the adjusted model only being a male living with the mother family support christian orthodox religious affiliation and frequent attendants of religious fellowships remained significantly associated with having ever used drugs for recreational purposes students who live in the same household as their mothers had lower odds of having ever used drugs for recreational purposes compared with those who did not students who receive adequate family support were 52 less likely to have ever used drugs for recreational purposes compared with those who received insufficient or no support christianorthodox religious affiliation was associated with a lower likelihood of drug use for recreational purposes with students who attended orthodox churches being 43 less likely to use drugs for recreational purposes compared with those who were muslims also those who attended religious services at least twice a week were 87 less likely to have ever used drugs for recreational purposes compared with those who attended only once a month or a year current drug use the prevalence of current drug use for recreational purposes was 175 with significant sex age and family characteristics variations in the unadjusted model presented in table 3 sex age living in the same household as ones father mother alive living in the same household as ones mother family structure family support religious affiliation and higher frequency of religious attendance were associated with recreational drug use however age living in the same household as ones mother family support and frequent religious fellowship attendance remained significantly associated with current drug use for recreational purposes in the adjusted model adequate family support was protective against recreational drug use individuals who received adequate support from home were 53 less likely to currently use drugs for recreational purposes compared with those who did not students who lived in the same household as their mother were 71 less likely to currently use recreational drugs compared with their counterparts who did not students who fellowshipped in orthodox churches were 44 less likely to use drugs for recreational purposes compared to those who were muslims also those who attended religious services every day or at least twice a week were 86 less frequency of drug use the findings on the frequency of drug use are shown in fig 1 the median number of days participants used drugs over the past month was six days of the 137 students who currently use drugs 238 used drugs in more than 10 days of the last month males were significantly more likely to have used drugs for more than 10 days of last month before the study compared to females discussion our study is motivated by the paucity of data especially among university students on recreational drug use in nigeria given the media attention to the abuse of drugs such as tramadol and codeine our study is timely and provides vital data for policymakers tasked with addressing illicit drug use in nigeria the present study shows that approximately a quarter of the university students in nigeria have ever used substancesdrugs like codeine marijuana and tramadol among others while close to onefifth are current users the only study conducted among university students in nigeria 26 is outdated and reported a low prevalence of drug use compared to our study a study has shown that the prevalence of drug use has increased since the 1990s 8 also the abuse of tramadol and codeine in particular may have contributed to the increasing prevalence of recreational drug use among young people in nigeria altogether there is a need to for policymakers to prioritise nigeria campuses for drug abuse prevention interventions considering the deleterious effects of drug use on the health of young people based on sem 20 factors that influence recreational drug use among young people operate at the individual microsystem mesosystem exosystem and macrosystem levels from our findings gender was the only individuallevel factor significantly associated with recreational drug use males were significantly more likely to use drugs compared to females similarly males are frequent drug users relative to females these results are consistent with previous studies on drug use 27 28 29 one plausible reason for this is that boys are more favourable to taking risks compared with girls boys generally engage more in unhealthy lifestyles relative to girls 30 another plausible reason for the observed gender differences in drug use in this study is cultural expectations there is more societal stigma and shame around women and girls drug use in the nigeria context 8 also this finding suggests that males are more exposed to the deleterious consequences of drug use compared to females however the prevalence of drug use is relatively high in both genders which suggests the need to target both males and females with any interventions tailored to address illicit drug use on nigerian campuses also based on sem 20 familyhousehold factors are important predictors of recreational drug use our study shows that being from a nuclear family was associated with a lower likelihood of drug use in the unadjusted model however the effect size was no longer significant after controlling for demographic factors previous studies have reported conflicting findings on the relationship between family structure and drug use among young people 31 32 33 34 some studies show that family structure is associated with drug use 32 33 34 however there is evidence that family structure had little impact on drug use after controlling for covariates 35 the plausible reason why the nuclear family had some effect on adolescent and young adults illicit drug use is that having and living with both parents means more parental monitoring training and control when one parent is away the other parent can take over the caring of the child unlike in a singleparent family we also found that living with ones father is protective against drug use in the unadjusted regression analysis but the effect size reduced and was no longer significant after adjusting for important covariates a study has shown that the presence of a father is protective against drug use especially for boys 36 the presence of fathers is important for adolescents and particularly boys our study further shows that living with the mother is protective against recreational drug use the protective effect of the presence of the mother in the life of young person against drug abuse is substantial and remains after controlling for important covariates students who lived in the same household as their mother had a lower likelihood of current and ever use of drugs compared with their counterparts who did not one explanation for this finding is that young adults who did not live with their mothers either as a result of death or divorce may experience behavioural challenges based on anecdotal knowledge mothers are essential for exerting control over the behaviours of young adults especially in nigeria where the burden of parenting lies mainly on mothers an alternative explanation could be those young adults who did not live with their mother either as a result of death or divorce use drugs as a coping mechanism for dealing with the loss of their mothers our explanation is bolstered by studies that established that the death of a mother could devastate the health and economic wellbeing of a family especially that of the children 37 38 39 40 children whose mothers died are abandoned by their fathers undernourished forced to drop out of school to take on difficult household and farm tasks and are far less likely to survive 37 38 39 40 overall the importance of having both mother and father present in the life of a young person cannot be overemphasised by and large the protective effect of mothers against drug use is far more significant compared with fathers our finding is supported by a study which demonstrated that drug use among daughters living with singlefathers exceeded that of daughters living with singlemothers 41 another key finding of this study is that adequate family support was protective against recreational drug use individuals who received adequate support from home were 53 less likely to currently use drugs for recreational purposes compared towith those who did not this study is consistent with a previous study that argues that parental support and monitoring are important predictors of young peoples health outcomes 42 our study provides strong evidence for the importance of family support as a protective factor against illicit drug use a study has established that young people who have strong bonds with their families are less likely to use recreational drug 43 the importance of family support on young peoples illicit drug use is noted in a study that shows that high levels of parental monitoring and family support were effective in buffering the relation between witnessing violence with the initiation of cigarette as well as advanced alcohol use at low levels of witnessing violence 44 however a study showed that patterns of drug use among young people coincided with patterns of family conflict but not family support 45 we also found strong evidence in support of the protective effect of religion on recreational drug use frequent association and fellowship with other people tend to serve as social control against illicit drug use religion has a strong influence on the lives of young people it serves an important agent of socialisation and an institution where young people are taught to behave well and follow religious norms religious teachings forbid delinquent behaviours it teaches young people to follow the laws which prohibits illicit drug use religion acts as a form of social control against illicit drug use and those that regularly worship tend to abstain from illicit drug use the limitation of this study includes the use of crosssectional design which does not provide information on causal inference we conducted this study among a subset of nigerians young people who are more educated compared to others as such our study is not generalizable to all young people in nigeria also we did not ask questions about specific drugs or the use of multiple drugs as such we are unable to estimate the prevalence and correlates of use of specific drugs further we did not examine the role of peer influence and other structural factors on recreational drug use in this study despite these limitations our study advances the discourse of recreational drug use in the nigerian context and identifies key protective factors against drug use future studies should estimate the prevalence of the use of specific drugs like codeine syrup tramadol and cannabis as well as the influence of peers on recreational drug use conclusion this study estimated the prevalence of and examined the correlates of recreational drug use among nigerian university students our results showed a high prevalence of recreational drug use among students with significant sex variations given the study findings and harmful consequences of illicit drug use there is a need for interventions to address recreational drug use on nigerian campuses the sem provided a framework for understanding the influence of individuallevel factors familyhousehold factors and religion on recreational drug use among adolescent and young adults our findings underscore that relevance of sem in understanding adolescent and young peoples behaviours even though sem did not inform the design of this study it proves relevant in understanding the context in which family factors impact adolescents development one criticism of sem is that it is difficult to evaluate all its components empirically we did not include other important sem factors including peer influence and structural factors such as governmental policies and law enforcement in our study as such our study did not evaluate the overall applicability of sem rather it drew from sem to understanding the factors influencing adolescents and young adults drug use data underlying the study is from s1 dataset of the published article data curation anthony idowu ajayi formal analysis anthony idowu ajayi investigation anthony idowu ajayi methodology anthony idowu ajayi supervision anthony idowu ajayi writing original draft anthony idowu ajayi oluwaseyi dolapo somefun writing review editing anthony idowu ajayi oluwaseyi dolapo somefun

given the paucity of data on recreational drug use and the recent media attention on the abuse of drugs such as codeine cough syrups and tramadol in nigeria our study examined the prevalence and frequency of recreational drug use among young adults from two nigerian universities we drew from the socioecological model to examine the influence of factors at the individual and family level on recreational drug use among adolescents and young adultsthis crosssectional study was conducted between february and march 2018 among a final sample of 784 male and female university students selected using stratified random sampling binary logistic regression was used to identify significant predictors of ever use and current use of drugsour analyses showed that 245 of students had ever used drugs for recreational purposes and 175 are current users the median drug use frequency over the past month was six days among current users n 137 in the multivariable analyses living in the same household as ones mother aor 028 95 ci 016049 adequate family support aor 048 95 ci 026089 and frequent attendance of religious fellowships aor 013 95 ci 007025 were significantly associated with a lower likelihood of recreational drug use however male sex aor 152 95 ci 105221 was associated with higher odds of recreational drug usethe family should be considered as an important unit to sensitize young people on the harmful effects of drug use it is also vital that religious leaders speak against drug use in their

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introduction children who are left behind in rural regions are those who can no longer live with both of their parents because one or both of their parents has moved away for a variety of reasons 1 children who are left behind in rural regions are a result of a certain stage of social and economic development people from many areas of life are concerned about the problematic behaviors of these kids as is well known parents assist children in building a secure loving connection offering emotional support enhancing selfcontrol and acquiring social skills 2 however migrant labor will also boost household income and lessen investment restrictions on education which will enhance the educational standing of children who are falling behind and raise their chances of enrolling in school as a result the educational possibilities for rural children who fall behind in the obligatory school stage have significantly improved and the gaps between these children and nonleftbehind children have steadily shrunk or even vanished the academic performance of leftbehind children is much worse than that of nonleftbehind children and the fact is that leftbehind children in rural regions are still in a clear disadvantageous position in terms of academic accomplishment and educational attainment the educational success of children who are left behind is significantly harmed by parental relocation 34 meanwhile in order to examine the effects of parental relocation on the academic achievement of leftbehind children data from 18181 fourthgrade students from 166 rural schools in five provinces were collected these students data came from largescale sample surveys conducted in rural areas in 2014 2015 and 2016 the study also investigates whether parents moving to cities for employment has both good and negative effects as a result the second section of this paper discusses rural parents relocation and the situation of the children who were left behind investigate the effects of different types of families on the academic performance of leftbehind children whose parents move to cities and find out whether adverse effects and positive effects play a role simultaneously 5 status analysis the negative influence the previous research found that children whose parents migrated had a considerably greater overall frequency of problem behavior than children who were not left behind when one parent migrates the likelihood of problem behavior in the children is much higher when the mother migrates than when the father migrates childrens academic performance is significantly influenced by aspects related to education including family education spending involvement in education and supervision in school this paper makes the case that children who are left behind in family education as a result of their parents migratory employment are less academically successful children who are left behind may experience different levels of concern depending on the migration patterns of their parents when wang et al compared the anxiety symptom scores of leftbehind children in grades 5 to 8 with both parents working outside the home and those who only had one working outside the home they discovered that the latter group scored higher 6 additionally some studies have shown that children who are left behind and are cared for by their grandparents parents who are also migrant workers perform better than children whose parents are also migrant workers 7 the parentchild bond is more likely to suffer harm in leftbehind children whose mothers migrate because they are more susceptible to their parents migration it is also simple to produce the worry problem through a followup study zhao jinxia et al discovered that the mothers psychological control over them and the emotional support from their peers and teachers were key factors in reducing the risk of leftbehind children whose fathers immigrated to china 8 in conclusion children who are left behind are more likely to experience anxiety issues when both of their parents commute outside of the city than both left behind and nonleftbehind children who only have one parent commute outside of the city the depression of children who are left behind is affected differently by the various parental migration patterns compared to children with one working parent outside the home children with both parents working outside the home experience higher levels of stress and depression in addition leftbehind children whose parents are cared for by relatives or no one takes care of both parents are more susceptible to internal issues like depression than leftbehind children whose parents work or those whose grandparents look after both parents while they are away additionally spending time away from both parents increased the chance of depression getting worse the incidence of depression among children who had one parent working outside the home was also significantly different at the same time children whose parents moved away from home experienced depression at a significantly lower rate than children whose parents stayed behind the early stages of parent separation were when the difference mostly happened conversely children whose parents both worked outside the home had lower mental toughness than children whose parents did not and the lower mental toughness was typically associated with a higher depressive feeling in general children of migrant workers with both parents have a higher risk of depression than children of migrant workers with only one parent and children of migrant fathers have a significantly lower rate of depression than children of migrant workers with both parents and children of migrant mothers who are left behind the positive effect however the resilient traits of children who are left behind play a certain advantage in the context of parents migration in some scholars investigation and research into childrens psychological behavior in trying circumstances some academics discovered that kids exhibited good adaptability instead of the anticipated psychological issues suggesting that kids may have some antifrustration potential 5 children may therefore be better able to withstand risks when they find themselves in the situation of being left behind the leftbehind children in rural areas understand that the family responsibility taken on by their parents is a decision they are compelled to make in order to raise the living standards of their family members when they have a positive interpretation of the reasons why their parents leave their hometown for work as a result when they stay behind and encounter challenges and setbacks it is challenging to ask their parents for assistance however they can logically analyze the roles played by family members refrain from griping and lessen the trouble brought on by a lack of security on the other hand leftbehind children have stronger autonomy the capacity for selfdecision and selfplanning as an engaged person is referred to as autonomy eriksons eightstage theory of personality development states that children must go through a crisis process from autonomy and shyness doubt to oneness to oneness difficulty each stage has a particular developmental objective their ability to handle their own affairs exercise selfcontrol plan ahead and realize their own potential can be improved by their independence diligence and initiative in the absence of their parents children who are left behind are forced to develop their own decisionmaking skills which makes it simpler for them to gain an advantage in group activities and social interactions and experience jump forward growth many youngsters who are left behind are also trained to assist their grandparents with household chores which develops their independence past research the relocation of rural parents will have a significant impact on how children live and learn as well as how well they will do on the labor market in the future 910 children from rural areas who were left behind will play a significant role in chinas future labor force children who are left behind in education are extremely important for national economic and human capital development as well as for their own growth many studies have been conducted on the education of children who are left behind both domestically and overseas existing research has examined how parental relocation impacts the academic performance of leftbehind children because the majority of them are in the nineyear compulsory education stage but the results have been mixed according to certain research children who are left behind academically suffer when their parents relocate for work 10 11 12 other studies have discovered that parental migration can help improve or at least not reduce the scores of children who are left behind 13 14 15 16 17 according to a study conducted on 13000 rural students parental migration considerably improved the academic performance of children who were left behind particularly those who had low test scores based on a comparison of 141000 children who were left behind and kids who were raised by their parents 1516 the fact that parental migration can have both favorable and unfavorable consequences on the academic performance of children who are left behind explains in part why the conclusions are inconsistent these beneficial and detrimental impacts are combined to produce the ultimate result in the empirical study that was previously discussed favorable consequences include parents being able to raise their familys income by relocating to urban areas for employment which frees up families mobility as well as having a favorable impact on childrens research through higher investment in education 131418 because working in cities exposes parents to more information about the advantages of education such as access to better jobs parental migration helps promote favorable expectations for a return to education solutions alleviate the behavioral problems the first is to control how people interact with one another children who live in rural areas who are left behind benefit from the support of their families schools and communities they can develop resilience with the aid of positive relationships with their parents teachers and the community aiming to provide leftbehind youngsters in rural areas more agency their interpersonal relationships should be regulated and paid more attention relationships with parents teachers and the community can be improved by participating in worthwhile practical activities the use of activities like role playing and empathy can help leftbehind children in rural areas fully comprehend their parents original motivation for working as migrant workers personally experience the challenges of being uprooted from their hometowns and achieve mutual understanding in a cooperative relationship it is possible to lessen the sense of oppression in the traditional teacherstudent relationship and make teachers support a dependable force for leftbehind children in rural areas when they face challenges by implementing teacherstudent fellowship activities and tightening the relationship between teachers and students getting kids involved in community development can help them develop a sense of their shared identity which will help leftbehind kids reject and lessen the sense of inferiority that comes with being called leftbehind and feel cared for and loved by everyone second creating an efficient risk prevention system can assist youngsters who are left behind in handling problems and emergencies on their own children who are left behind cognitively should be assisted in fully interpreting leftbehind behavior in a good light assisted in the development of dialectical thinking and assisted in seeing things from two perspectives children who are left behind in rural areas should be told that they can manage their own problems and should be given complete trust and expectations children who are left behind will feel more effective when they overcome obstacles and succeed on their own via selfstrength children that are left behind will acknowledge their special skills with constant encouragement and assistance children that are left behind will acknowledge their special skills with constant encouragement and assistance even without their parents there kids are able to solve a variety of problems for youngsters who are being left behind famous cases of people who face challenges and overcome them should be taught in everyday instruction in addition they should be made aware of the resources available to them in case of emergencies as well as the precautions being taken to ensure that leftbehind children living in remote regions have someone they can turn to for assistance solve the existing educational problems the aforementioned regression results dont match up with the majority of studies on how parental migration affects the academic achievement of children who get left behind one reason for the regression results in the table is that after a year of parental relocation adverse impacts start to manifest shortterm consequences of parental migration are detrimental to the children who are left behind the longterm negative effect of parental migration on children left behind gradually fades away after two years of parental departure because the cumulative positive benefit is higher than the negative effect the results of the majority of research are contradictory to those of this paper because they do not account for the order of these two effects hu and li discovered that children who are left behind in math or chinese perform significantly worse when one or both parents migrate for longer than six months 19 the study also discovered that remittances made by immigrant parents to their home countries can somewhat offset this adverse effect however it did not look at the precise moment at which this income effect starts to take effect the extent and length of the favorable and unfavorable effects of parental migration have been the subject of numerous research according to tao and zhou only when both parents move for an extended period of time will their childrens academic performance suffer significantly 20 additionally the importance of childcare outweighs the positive income impact making it unlikely that the academic performance drop caused by a parents move will be offset by an increase in family income tao and zhou defined kids with two parents moving as leftbehind children but the definition included students with at least one parent moving which may be why the results of the research mentioned above differ from those of this paper 21 conclusion in order to evaluate how parental migration affects the academic performance of children left behind data from prior studies from 2014 to 2016 were also analysed the results showed that one year after parental migration the negative impact plays an immediate role as evidenced by the childrens declining academic performance however two years following parental migration the benefits start to exceed the drawbacks and the offspring of those who were left behind are no longer impacted the author discovered that in contrast to majority of previous studies the advantages and disadvantages of parental migration manifest themselves at various stages of life in actuality the relocation of parents will result in a lack of care and supervision for the studys leftbehind children other careers can take care of the children left behind but none can give them the sense of security that their parents can as a result in the short term the negative impacts of parental migration are more noticeable following a period of emigration parents send money to their rural homes to pay for their childrens education and lessen the burden that schooling places on their kids ability to work and support themselves immigrant parents place greater focus on educating their childrens education and use more of their income to invest in their childrens education as a result of migration to cities which has exposed parents to more information and opportunities and raised their hopes for a return to school immigrant parents would reiterate to their children the idea that education will make it simpler for them to find a better job based on their experience working in cities

the group of leftbehind children in china has long been characterized by largescale and numerous challenges among which the education of leftbehind children has been the center of attention and a contentious topic in china there were 170 million rural migrant laborers by 2022 rural migration may have a significant positive influence on the families communities and work force of the migrants as well as on themselves personally it is important to investigate how these massive rural migratory workers affect the family unit particularly their children the object of this paper is the leftbehind children in rural areas under the background of parents migration there are two main research directions the first is the behavioral problems of leftbehind children in rural areas under the background of parents migration and the causes and countermeasures of the behavioral problems the second is the education status of leftbehind children in rural areas under the background of parents migration children whose parents migrated had a considerably greater overall frequency of behavior problem than children who were not left behind when one parent migrated the likelihood of problem behavior in the children was much higher when the mother migrated than when the father migrated childrens academic performance is significantly influenced by aspects related to education including family education spending involvement in education and supervision in school

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the second aim of the current paper was to gather first evidence whether the affective state of the sender can also be communicated across cultures the influence of culture on emotional communication is a key question in all forms of emotional communication such as facial expressions 20 and emotional prosody in speech 21 the overall finding is that basic emotions such as fear happiness sadness anger disgust and surprise can be recognised across cultures with an ingroup advantage for listeners of close cultural proximity 22 23 24 recent articles showed that laughter expression is also shaped by cultural influences 25 26 27 while laughter among other nonverbal vocalizations can be recognized across cultures there was an ingroup advantage for cultures of close proximity indicating the existence of cultural influences on the perception of nonverbal emotional vocalizations 27 with respect to laughter kamiloğlu et al 25 reported that laughter sounds more positive when produced by listeners close to the senders own culture for nonverbal vocalizations it has been shown that even though it is unclear whether listeners are generally able to identify the cultural background of the sender on the basis of the nonverbal vocalisation 252628 there seems to be an improved emotion recognition of ingroup signals 28 a similar cultural ingroup advantage might also be expected for the classification of laughter sounds according to the affective state of the laugher taken together while there are indications that laughter in general is a crosscultural phenomenon which may be influenced by the cultural background studies investigating whether the affective state of the laugher is communicated across cultures are missing to test this in the current paper we used a set of spontaneously emitted joy schadenfreude and tickling laughter stimuli voiced by german speakers as created and used in szameitat et al 12 and tested how well the different types of german laughter were recognised by listeners from the uk poland india hongkong and a mixed group of nongerman listeners not fitting any of the other categories we predicted first that listeners from other cultures are able to classify spontaneous german laughter according to the senders affective state above chance level and second that classification rates are higher for listeners with a close cultural proximity to the german culture methods stimulus material we used a set of 121 spontaneous laughter stimuli generated by 39 german speakers as used and described in experiment 2 in szameitat et al 12 joyful and schadenfreude laughter was generated by groups of friends watching funny video clips together the video clips were chosen to elicit various emotional responses eg clips from positive funny situations and clips which were meaner in nature for more methodological details on the stimulus material please refer to szameitat et al 12 please note that it is not possible to directly compare the results from szameitat et al 12 with the current study due to some methodological changes procedure the study was conducted online using psytoolkit 2930 after providing informed consent participants were instructed and then practiced the classification task with 12 laughter sequences which were not part of the main stimulus set participants were played a laughter sequence and were asked to indicate whether they thought the laughter sounded most like joy schadenfreude or tickling to give the answer participants had to choose one of three answer boxes that were presented horizontally on the screen by mouse click participants were asked to first listen to the full laughter sequence before giving their answer they were able to listen to the same sequence as many times as they wished before giving an answer the experimental software did not record how often participants made use of this option but incidental observations of inperson testing in other studies suggest that participants very rarely listen more than once to a stimulus once an answer box had been selected the next laughter was played the 121 stimuli were split into four blocks of 3031 stimuli per block with the option to have a break between blocks the order of stimuli was randomised across participants there was no time pressure during the experiment and the average total duration was about 20 min statistical analysis for all statistical tests wagners 31 unbiased hit rate for correct classification and wagners proportion correct were calculated for each participant and laughter type individually the comparison of h u with p c accounts for false alarms uneven stimulus distributions and response biases 31 for convenience for illustration in tables and figures we report hit rates results descriptive statistics across laughter types correct recognition rates were around 50 with the highest rate for the other group and the lowest rate for hong kong split up for group and laughter type the highest recognition rate was 559 for schadenfreude in the other group and the lowest rate was 401 for tickling in the hong kong group table 1 shows that the hong kong sample had a higher mean age as compared to the other groups to test weather this affected the results we removed the 7 oldest participants leaving a sample of 18 participants with a mean age of 3344 years which was comparable to the polish sample the recognition rates for this agematched sample did not differ notably from the full sample in more detail the overall recognition rate across laughter types was 4293 instead of 425 for joy 4389 for schadenfreude 4176 and for tickle 4259 therefore the higher mean age of the hong kong sample did not affect the recognition rates table 2 cultural background of the different groups participants were categorised by the culture they identified most with there was a further group other with participants from various backgrounds see text for details pmfpob place of birth participantmotherfather pmflived where did they live most of their lives example in the hong kong group all 25 participants identified most with the hong kong culture although one of them was not born in hong kong and three of them did not live most of their live in hong kong and five of them had mothers not born in hong kong and so forth note that most not hong kong answers in the hong kong group where china can type of laughter be recognised within each group while for illustration the tables and figures show hit rates we used h u and p c for all statistical tests all tests were based on the relative difference between h u and p c reflecting recognition abilities if h u and p c are identical this difference is 0 and reflects that participants are not able to recognise laughter above chance level in the following we call this measure h upc to test whether laughter can be recognised above chance level we first calculated five onesample ttests of h upc versus 0 averaged across all laughter types for all groups recognition rates were significantly above the chance level of 33 in more detail overall recognition rate for poland was 499 8944 p 0001 cohens d 4104 for the uk 504 10199 p 0001 cohens d 3400 for india 482 10978 p 0001 cohens d 3310 for hong kong 425 5659 p 0001 cohens d 2310 next we tested whether each individual laughter type can be recognised above chance level for this we calculated onesample ttests of h upc versus 0 separate for each of the 5 groups and 3 laughter types results showed that within each group each laughter type was recognised significantly above chance level 12099 df 2444 see supplementary online materials for full statistics above we calculated 20 ttests overall which inflates the likelihood of an alpha error accordingly we controlled the familywise error rate to p 005 using bonferroni correction for illustration we applied the bonferroni correction by multiplying the pvalues of all the above analyses by 20 even after bonferroni correction for 20 tests all above results remain statistically significant 17 of the 20 comparisons are p 0001 if bonferroni corrected only the individual laughter types for the hong kong group did not meet this level recognition rates did not differ between male and female participants 1182 p 0392 data separate for each group are provided in the supplementary online materials in the above analyses we determined recognition accuracy across participants another view to inspect the data is to test how many participants individually show a significant recognition rate to test for statistical recognition in individual participants we calculated a χ 2 test for each participant based on the expected and observed frequencies for joy schadenfreude and tickling laughter the χ 2 tests revealed that 75 of the participants showed significant recognition rates with p 005 and 59 of the participants even at a significance threshold of p 0005 split by group 85 of the other participants 84 of the uk participants 80 of indian participants 75 of polish participants and 40 of participants from hong kong showed significant recognition rates with p 005 taken together these latter analyses and fig 2 show that the further above reported significant recognition rates on the grouplevel are not caused by a few superrecognisers but instead reflect the majority of participants for a deeper understanding of how the different stimuli were classified into the different categories we calculated the confusing matrix the confusion matrix shows that for each given stimulus category the according response category was the most frequently chosen response to identify potential confusions we tested whether other categories beside the correct target category also showed significant hit rates above chance level of 33 the only statistically significant confusion was that 36 of the schadenfreude stimuli were classified as joy while the reverse relationship was not significant this confusion figure 2 histogram showing the overall recognition rates across all groups bin width 1 the red vertical line shows the chance level of 33 separate histograms for each group can be found in the supplementary online materials is expected to some extent because schadenfreude per definition also contains an element of joy to assess whether participants showed consistent patterns we calculated intraclass correlation coefficients as a measure of interrater reliability averaged across all groups iccs were high to very high when split by group the lower number of participants resulted in lower iccs which were roughly comparable across groups the full data can be found in the supplementary online materials taken together the results show that all laughter types were significantly recognised above the chance level of 33 with recognition rates varying between 401 and 559 regarded on the level of individual participants 97 of all participants showed recognition rates numerically above the chance level of 33 and 75 of all participants showed statistically significant recognition do the recognition rates differ between groups our second hypothesis was that the recognition rates might differ between groups and that groups coming from more distant cultures may show lower recognition rates as compared to groups from closer cultures because poland and uk both european countries rather close to germany can be considered close cultures and india and hong kong are both rather distant to germany we created two groups close and distant the other group was not considered for this analysis because participants in that group came from all around the world the resulting close group had an overall recognition rate of 522 which was significantly different from the chance level of 33 13485 p 0001 cohens d 3604 the distant group had an overall recognition rate of 462 which was significantly different from the chance level of 33 11735 p 0001 cohens d 2825 in particular the close group had a 6 higher recognition rate as compared to the distant group which was significant 3141 p 0002 cohens d 0562 the same pattern was observed when the laughter types were analysed separately ie all laughter types were recognised above chance level in close as well as distant groups and recognition rates were always significantly higher in the close as compared to the distant group 2197 p 0030 schadenfreude close 544 distant 437 t 2372 p 0019 tickle close 492 distant 451 t 2977 p 0003 to test whether laughter type and group may interact we calculated a 2 × 3 mixed anova with the betweensubject factor group and the withinsubject factor laughter type the dependent variable was h upc across the groups the recognition rates differed significantly between laughter types 84552 p 0001 partial η 2 0403 across laughter types the recognition rates also differed significantly between groups 9864 p 0002 partial η 2 0073 the interaction between laughter type and group only approached significance 2751 p 0066 partial η 2 0022 discussion summary of results the first aim of the current study was to test whether the type of laughter spontaneously produced by german speakers can be recognised by a large sample of listeners from different cultural backgrounds results showed that listeners from poland the uk india hong kong and a mixed group of other cultures were all able to recognise each laughter type significantly above chance level with recognition rates varying between 401 and 559 the second aim of the current study was to test whether the cultural background may modulate the recognition rates we found that cultures close to germany showed on average 6 higher recognition rates than the cultures distant to germany suggesting cultural influences in identifying affective laughter types crosscultural recognition of laughter we found that laughter sounds can be classified according to the affective state of the sender significantly above chance level by listeners of diverse cultural backgrounds suggesting that laughter expression is not culture specific that affective laughter types can be identified crossculturally is in line with findings that also other socially relevant information is communicated to outgroup members via laughter for example listeners of different cultures can tell if spontaneous laughs produced in conversations are uttered in company of a friend or of a romantic partner even when the laugher was not from the listeners culture 6 moreover bryant et al 5 showed that listeners of 24 different societies were able to tell if laughter was directed to a friend or a stranger irrespective of the cultural background of the laugher interestingly listeners were able to classify laughter even if the laughter sound was very short suggesting that classification of laughter affords a rapid appraisal of affiliation 5 in a study by kamiloğlu and colleagues 25 japanese and dutch listeners were even able to tell the cultural background of the laughter just by listening to different laughter sounds in addition there is increasing evidence that listeners can tell if the laughter was emitted spontaneously or if it was produced voluntarily again irrespective of the laughers culture 72526 interestingly sauter et al 27 investigated a diverse pool of different nonverbal vocalizations and found that laughter was the only nonverbal vocalization that was reliably classified crossculturally by listeners of distant cultures namely himba and english listeners moreover both listener groups agreed that laughter communicates amusement and is uttered when being tickled our results show that also negative laughs such as schadenfreude laughter can be classified crossculturally and that listeners are able to distinguish between amusement laughter and negative laughter irrespective of the cultural background this suggests that while laughter has primarily evolved as a play signal between nonhuman primates that signals the enjoyment of physical play 27 it can also be used to ridicule and exclude others from group context 32 importantly our study suggests that such a negative message is also communicated reliably to outgroup members that are not part of the laughers culture crosscultural differences research on the crosscultural expression of emotions in the human voice in general has consistently demonstrated an ingroup advantage ie listeners from the same culture as the sender recognise emotions with higher accuracy than listeners from a different culture 24 in addition there appears to be a gradient so that the more distant senders and listeners cultures are the lower the emotional recognition tends to be 2224 our findings are in line with this as close cultures showed on average 6 higher recognition accuracy as compared to distant cultures our findings are in line with research showing that listeners performed better when classifying nonverbal vocalizations produced by members of their own culture 27 interestingly in order to show an advantage in classifying signals from ingroup members it is not necessary to be able to consciously differentiate between ingroup and outgroup signals 28 suggesting that affective appraisal is a very quick subconscious process in contrast to our results farley and colleagues 6 found that irrespective of the cultural background of the laugher listeners are equally good at classifying laughter emitted by friends and romantic partners the authors suggested that the lack of an ingroup advantage might be due to limitations in sample size or to having limited information about the cultural background of the listeners 6 therefore whether appraisal of affiliation shows a similar ingroup effect as appraisal of the affective state is still unclear overall while it is still unclear whether listeners are able to identify the senders cultural background in laughter 25but 26 listeners of close cultures show an advantage when decoding information relevant for social cognition such as affective content and maybe also group affiliation even when listening to short segments of laughter communication of information in laughter laughter can be differentiated according to the senders affective state on the basis of the mere acoustic signal regardless of whether it is produced spontaneously or voluntarily the current results confirm this for a crosscultural participant sample for laughter produced by actors we have shown that the laughter type is encoded in acoustic parameters such as peak frequency and centre of gravity 33 and the emotional dimensions arousal dominance and valence are encoded in fundamental frequency and temporal parameters 34 that the acoustical signal of laughter alone can communicate information about the sender has also been reported by wood and colleagues who found that the laughs acoustics depend on the affective context in which the laughter was emitted ie reward affiliation and dominance in spontaneous laughs 15 as well as in voluntary laughs 14 likewise it has been shown that mirthful laughs differ acoustically from polite laughs spontaneously produced in conversations 16 that the affective state of the sender is communicated by the mere acoustical signal has also been shown for other nonverbal vocalizations for example holz and colleagues 35 found that listeners are able to judge emotional expressions above chance level in voluntary nonverbal affective vocalizations such as cries moans and screams a similar study was done by engelberg et al 36 who similar to our studies on laughter did not compare different nonverbal vocalisations but investigated one single type of nonverbal vocalisation ie screams engelberg et al 36 showed that the acoustical properties of screams emitted in various affective contexts taken from movies and tv presentations differed depending on the affective context therefore growing evidence suggests that the affective state is not only communicated by varying the type of nonverbal communication 27 but that even single types of nonverbal vocalizations can communicate the affective state in a fine grained fashion however some studies did not observe that the mere acoustical signal of laughter can communicate affective states 1819 the reasons for these discrepant findings are not clear but might at least partially be caused by differences in the methodological design for example rychlowska et al created situational contexts to elicit certain emotions such as eliciting schadenfreude by participants watching someone else losing a game however the situational contexts may have resulted in some participants experiencing other emotions such as empathy or pity when watching someone losing this incongruence between intended situational context and perceived emotion is something we observed in szameitat et al 12 where for example by far not all participants reported having felt schadenfreude after watching videos which we deliberately selected to elicit schadenfreude noteworthy in the current study each laughter stimulus is assigned to the respective category based on the emotion the laugher reported and not based on the nature of the video they watched therefore generally we believe that it is the actually experienced affective state which is encoded into the laughter signal and not the situational context as such limitations the current study was not designed as a crosscultural study for example the sample sizes of some groups are comparatively small for a crosscultural study therefore one should be cautious in making strong inferences about specific characteristics of the cultural groups investigated given that there are only very few studies investigating the communication of affective state in laughter we believe that the inclusion of a variety of different cultural groups had two main benefits first we provided the proof that in the most generic sense affective communication in laughter can work across cultural boundaries while this has been shown for other aspects of laughter 5 this is the first time that it is shown for the communication of the laughers affective state second we were able to show that this communication appears to be modulated by the cultural distance again caution may be advised when inferring about specific cultures but the current study showed that in general affective communication in laughter aligns with the common patterns shown for other forms of affective communication while we assessed the cultural backgrounds of the participants and their parents we did not assess whether participants had contact to the german culture it could be argued that contact to the german culture eg by visits to germany or having friends from germany may affect the sensitivity to perceiving the correct affective state of german laughter future studies may test whether such factors may indeed affect the recognition rates conclusion overall the mere acoustical signal of laughter is a tool to communicate different aspects relevant for social communication such as affiliation between sender and listener 56 honesty of the signal 725 and affective state of the sender as shown in the current study and by others 121415 while we believe that the combination of vocal laughter expression emotional facial expression and knowledge of the situational context is most potent for the communication of affective social information our key finding is that the acoustical signal alone is already sufficient to communicate affective information across a range of cultures data availability all data generated in this study are included in the supplementary online materials of this published article received 29 june 2023 accepted 3 february 2024 competing interests the authors declare no competing interests

laughter conveys a wide range of information relevant for social interaction in previous research we have shown that laughter can convey information about the senders emotional state however other research did not find such an effect this paper aims to replicate our previous study using participant samples of diverse cultural backgrounds 161 participants from poland the uk india hong kong and other countries classified 121 spontaneously emitted german laughter sounds according to the laughter type ie joyful schadenfreude and tickling laughter results showed that all participant groups classified the laughter sounds above chance level and that there is a slight ingroup advantage for western listeners this suggests that classification of laughter according to the senders emotional state is possible across different cultures and that there might be a small advantage for classifying laughter of close cultural proximity laughter is a nonverbal signal that plays an important role in social interaction and affects the emotional state of laughers 1 and listeners 2 alike in recent years the function of laughter as a communicative tool has been extensively investigated however empirical work on how people perceive laughter is still limited 3 one of the main questions is what kind of information is communicated from the person who laughs sender to the listener receiver by means of the mere acoustic laughter signal ie without information about facial expressions or the context in which the laughter is uttered for example research has shown that laughter can communicate information regarding affiliation and group structure ie listening to laughter listeners can infer the social status of the sender 4 and whether the sender laughs among friends versus strangers 5 or among friends versus their lover 6 moreover listeners are able to perceive whether laughter is uttered spontaneously or voluntarily also called posed or faked laughter 7 8 9 in addition there is accumulating evidence that laughter like facial expressions 10 and emotional prosody in speech 11 can communicate information about the affective state of the laugher for example in previous studies we were able to show that listeners can distinguish between spontaneous joy laughter schadenfreude laughter laughing about the misfortune of someone else and tickling laughter 12 and between joy schadenfreude taunting and tickling laughter generated by professional actors 13 in line wood and colleagues showed that the acoustic variation of laughter taken from a commercial sound database acted laugher is linked to the perception of reward affiliation and dominance 14 and that spontaneously emitted laughs natural laugher emitted in different social contexts show distinct acoustic profiles 15 furthermore spontaneous laughter produced in conversations differs acoustically from mirthful laughter 16 however the general notion that the mere acoustical signal of spontaneous laughter can communicate the affective state of the sender without any contextual information has been questioned for example scott 17 suggested that it is mostly the situational context of the listener receiver which determines the perception of the laughter sound eg whether one feels being laughed at this suggestion is in line with empirical findings by rychlowska et al 18 who found that listeners were able to classify natural laughter that was uttered in situations evoking amusement embarrassment and schadenfreude only with contextual information but not based on the acoustical signal alone in line with this suarez and colleagues suggested that laughter carries distinct emotions but that contextual information is necessary to distinguish the affective state of the laugher 19 therefore the first aim of the current paper was to provide further findings to the currently contradictory empirical evidence regarding the communication of the affective state in laughter 1218 for this we conducted a study similar to szameitat et al 12 but in a much larger and more diverse sample we predicted that the affective state of the sender can be recognised above chance level by listeners of diverse cultural backgrounds which would provide further evidence that the mere acoustical laughter signal can communicate the affective state of the sender without any situational context

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introduction this study focuses on the analysis of contacts and communications on twitter about pandemic policies the goal is both showing mobilization processes rising from the web and detecting main actors themes and contents within the european context the choice of twitter as a social network to monitor derives from several considerations the political nature of the debate leads us to believe that this social network is particularly useful the widespread and transnational use of the same social network allows you to compare information and narratives in different contexts using the language as a proxy for the area the possibility of identifying short phrases videos and links allows you to reconstruct the political and identity profiles the main question to be answered is if the online communication about the pandemic phenomenon produced something as social andor political common feelings with this in mind the work monitored the on line communication during different phases of pandemic crisis identifying a keyword for each we selected in particular three main topicsphases named as nomask covid19 greenpass a specific focus was on the protest communication when the nomask protests decreased the communication centered on the covid19 lemma was monitored this made it possible to compare the different communication structures the relative narratives the weight of protest communication and the persistence of dialogue on the more general topic of the pandemic the nomask and covid19 communicationalthough centered on the same issue differ in structure persistence narratives and also characterizing languages another communication structure is referred on a specific form of protest that against the covidpass this compared to the nomask one presents some specific characteristics the greater endurance over time and the particular presence of italian protests the decision to make mandatory a document certifying the immunization to allow the free movement of the population in fact assumed a different weight in each state and consequently the communication on this specific issue is mainly referred to areas in which the weight of the legislation was particularly stringent we did not want to analyse comments centered on only one keyword but to choice the characterizing topic each specific period this was possible by monitoring both the discussion in the media and the trend of the debate on social networks we opted for an analysis conveyed by the same trend of public opinion being the risk communication an important part of the social perception and construction of collective meanings the work therefore analyses the effects of the perception of the covid19 pandemic and related political interventions consciously with respect to its construction as a social event in fact can the on line communication be defined as a unique process the answer is no it cannot first of all the covid19 emergence issue as social and political topic changed in time for political relevance social perception narratives as real health threat and consequently for its economic impact so we distinguish at least three different phases of the pandemic crisis depending on the social perception political choices juridical decisions and subsequent economic impacts these phases are wellidentified even through a monitoring of the specific on line communication on twitter twitter as social network is particularly suitable for the purpose because each user has a small number of characters for each message which can be commented on or shared by others and at the same time the content and users are usually politically oriented moreover the on line communication was particularly spread between 2020 and 2022 when pandemic crisis affected all european states limiting direct contacts and encouraging digitization besides twitter is a very used platform in all states of european union and in england the use and platform availability is very important because comments on social networks underline different opinions and communities interests and intentions and we are interested in evaluating the incidence of choices and opinions but also of the structure of communication from a supranational point of view at the same times there are many different questions opinions problems related to the covid19 crisis we tried to identify different facets as the main themes and most relevant communities the main hubs that is the main users subjects or entities that send and receive a large amount of information the most relevant topics and languages even in a comparative perspective the underlined meanings and differences related to languages during some phase and period issues have certainly produced more than just a virtual protests or reactions in many european states on the other hand we also note some local specificities both with respect to themes and issues and with respect to the narratives characterizing the area it is interesting to note for example how in the early stages shortly after the tragedy that hit italy many of the italian comments extracted on the nomask keyword are aggressive or ironic but however opposed to the movement materials and methods while certainly one of the key actions of the government during the pandemic crisis was to make sense of the crisis conveying meanings and informing about risks and related decisions the acceptance of this meanings did not always happen most emergency risk communication is based on the assumption that technical and social improvements in the warning system can motivate people to take protective action contrary to popular belief it has become particularly clear how communicating risks to the population does not automatically lead to changes in behavior the work presented aims therefore to reconstruct the collective narratives related to the pandemic emergency by adopting different points of view and attempting to reconstruct the motivations that led to the prevalence of one or the other position this type of analysis wants to investigate the reasons of specific behaviors for or against emergency policies certainly an important concept in this sense is that of the social construction of reality here redefined in terms of digital ethnography and risk communication as well as the analysis of social communication to planning social policies ontological insecurity and digital culture is virtual experience itself important for the construction of cultural identities this is an important question for this study although this work focuses on the specific analysis of online communication it must necessarily address this issue as the relationship between the construction of shared political identities and online communication is becoming more and more relevant and certainly it has significantly impacted the topic of reference in fact this is an issue that cannot be ignored when confronting the perception and management of policies on the covid19 pandemic the on line communication could be considered in this sense a tool to understand the weight of the interaction between the micro and macro dimensions referred to the social construction of identities digital communication has become such an element of these process because of it is capable to produce meanings behavioral models and norms the communication on social networks today can in fact be considered as one of the elements that convey the construction of identity as it produces interaction and derives from prior positions and choices identity structure as well as awareness of a reference context or community are all features that help to produce ontological security this function is particularly important in the period we are dealing with cultural theory identifies specifically four cultural worldviews which may be relevant for the outcomes on the reconstructed debate individualism egalitarianism hierarchism fatalism according with this perspective reality is socially constructed through cognitive mechanisms with which people reproduce the expectations of their ingroup as a protective reaction against insecurity and fear this condition can lead to the spread of false information among groups and communities of users reducing ontological insecurity and relative perception of risk with results on individual andor collective behavior in this sense it was useful to monitor in particular communications centered on nomask and on covidpass specifically the issue of the diffusion of the confirmation bias linked to the individual selection of information and news that confirm ones prejudices including the sources of access to information is significant up to the creation of customized user profiles besides other biases may emerge or overlap with this by depending on additional on line or off line relational social and cognitive dynamics andor psychological distress and anxiety furthermore different studies highlight how behind conflicts there are causes that go beyond disinformation and individualism and that are related to many causes the sharing of misleading communications controversies and fake news crossed with a climate of widespread ontological insecurity usually produces a high risk of distortion in information besides considering the communication on social networks the algorithmic management of the sending of customized communications intensifies these identification and identity construction mechanisms initiating forms of access to disinformation that are no longer controlled even by the user himself the outcome of the process described is the growing polarization of messages and the public on social media these dynamics already noted and discussed due to the negative effects on the social political and relational level have assumed particular relevance for the possible effects on the health level linked to the diffusion of opinions contrary to vaccination and more generally against every precaution aimed at limiting the increase in infections and the most harmful effects of the pandemic the debate that emerged on social media and more generally on the media has produced unprecedented fractures including transversal ones on the political level which have ledin italyto the emergence of positions defined as communitarian liberal progressive and radical the role of ideology for the cognitive management of ontological insecurity is in this sense relevant people with more political knowledge have in particular more developed ideological positions likewise cultural worldviews are generally more consistent and their influences are stronger among people with political knowledge so we can distinguish multiple reactions to the pandemic crisis alternatively attributable to political ideologies and to the four cultural worldviews identified especially if we consider the original distinction of individualism vs communitarianism and egalitarianism vs hierarchism in fact we can identify a communitarian rightwing tending to be alarmist and a liberal rightwing oriented instead to minimize the gravity of the pandemic as well as a progressive leftwing asking for closures as measure extraordinary and a radical leftwing criticism against any closure as risk of authoritarian drift fsoc three european phases of pandemic crisis the pandemic crisis has certainly entailed exceptional and emergency conditions everywhere it has been necessary to impose more or less severe measures aimed at limiting infections in terms of ontological security the choices made more oriented toward opening than closing have certainly influenced the climate of opinion implying a specific balance between fears of contagion and the risk of impoverishment these positions certainly emerged from the analysis of the tweets with a certain distinguishable strength also in terms of different languages conveying some themes rather than others as we will note this implies several stages characteristics and related perceptionsdefinitions it is interesting to note that the three phases identified through the analysis of the comments and progressive findings that emerged from media monitoring correspond to as many distinct phases considering the spread of infections in the european context and related more or less binding political decisions the analysis of the communication on social networks allows to obtain therefore information relating to contexts and conditions even distant and different if this is certainly an advantage it was decided to limit the analysis only to the european context which has similar traits and in which the various states have moved with a certain homogeneity if in this context three specific moments are identifiable the conditionsat least in terms of the reconstructed phasescould change by including comments in other languages the first wave of the virus implies a phase of high alert in which almost all european states close schools many businesses and restrict public gatherings at various levels many states also involve the military reduce public services and introduce night curfews these decisions trigger protests mainly of a liberal andor individualist orientation continuing in europe also during the second wave of the pandemic in particular during christmas the second period is however a period of loosening of restrictions in which many european governments decide to adopt a less drastic approach than the previous lockdown with some alignment of approach but with time and regional lags in implementation at the beginning of 2021 many eu countries still adopt restrictive measures but not comparable to the strict closures of a year earlier germany and the united kingdom adopt a partial lockdown france spain and the netherlands instead adopt a curfew in this phase progressively the nomask protest diminishes while communication about the need for closures and the severity of the infection but also about the economic crisis remains and intensifies this is the period in which communication covid19 is monitored at this stage on the socioeconomic front european governments are committed although with different margins for maneuver to providing massive fiscal financial and economic support to protect businesses workers families and vulnerable populations national and european public funds are reallocated in favor of the priorities dictated by the crisis supporting healthcare vulnerable populations and regions particularly affected by the crisis these facilitations and supports certainly helps to limit protests and various forms of dissent lastly and precisely in relation to the centrality of the economic crisis a third phase of thematic communication on the pandemic emerges which does not occur in all areas with equal intensity and which refers to prohibitions and controls linked to vaccination andor immunization it concerns the need to have a document proving the immunization in order to be able to regularly attend public and private services offices and facilities on twitter the protest centered on the lemma greenpass emerges with particular force this is a phase in which socioeconomic benefits are becoming increasingly scarce and consequently protest and dissent centered on economic issues are increasing three topics of communication for three features of pandemic crisis the distinguishable forms of protest andor discussion in europe refer to phases and forms of evolution of the online debate related narratives and limits of mobilization although different phases can be identified for each context linked to the combination of the spread of contagion political decisions and the different balances that each area has maintained with respect to the need to protect public health and economic interests the work shows we can distinguish three specific moments of discussion the first phase of the pandemic was characterized by the nomask protest linked to the closure and distancing decisions that gradually emerged in this phase the presence and mobilization of the protest group is especially widespread in certain areas and is characterized by a refusal to adhere to forms of restriction of individual freedom the work monitors at this stage the recursive online communication between subjects critical of government choices against the risks of contagion underlying the pandemic we used in particular webscraping tools to extract tweets containing reference lemmas of communication with respect to measures to contain the contagion communication centered on nomask was monitored from november 2020 to february 2021 subsequently having noticed a clear reduction in reference communication the communication centered on covid19 was monitored from march until june 2021 finally the last monitoring phase concerned the lemma greenpass this observation lasted until december 2021 in march 2022 italy which prolonged the state of emergency for a particularly long period also declared its end the decision to monitor the use of these words depends on several considerations most of which have already been described referring specifically to the analysis of the data the word nomask becomes de facto irrelevant in february 2021 while later on especially in the summer dissent becomes macroscopic in relation to the ban on openings and aggregation between march and june there is no other clearly semantically connoted lemma so we opt to monitorfor comparative and evaluative purposesthe communication on covid19 this extractionkey makes it possible to distinguish between communication structures and themes the third phase identified through media monitoring and communication content analysis is the one in which dissent toward emergency measures becomes particularly incisive especially whereas in italythese still persist and strongly condition citizens lives especially when they decide not to vaccinate at this point the protest again becomes visible and associated with specific lemmas once again connoting itself on a thematic level if the headword changes explicitly leading back to the demand for proof of vaccination the protest reemerges again in association with the keywords of the first phase the media visibility of the new wave of protest is evident and transnational although it is concentrated in certain areas andin particularwe centered our analysis in the italian context results technically we propose a threestep procedure which is useful for obtaining information on data extracted from social networks using a number of analysis techniques borrowed from the indepth qualitative analysis graph theory and automatic content analysis concerning the graph theory users are defined as nodes and the comments links and images posted and viewed constitute the links in this way the hubs of the network are identified and all information regarding the relevance of the messages is reconstructed their attractiveness the potential for intermediation the selective reach of some messages as opposed to the ability to quickly reach many or all users of others is information that can be detected using the group analysis function and the various network analysis measures referring to centrality degree betweenness and closeness the same procedure has also been successfully used to analyse other forms of communication on social networks and allows for a kind of controlled nonautomated data mining skimming relevant information from a potentially infinite database of data and communications this approach captures and integrates information on several levels crossreferencing the preliminary qualitative analysis of the detectable information on the main network comments with the quantitative investigation of the network structure of the communication aimed at identifying the most significant structural elements specifically large samples of tweets were extracted systematically covering the emergence period for the most part of european states from november 2020 to march 2021 three main keywords were selected from the debate nomask covid19 and greencovid pass after collecting edges and comments in 13 waves we observed different structures of the nets representing links among users technically we remark a three steps procedure applied to obtain complementary information about data extracted from social networks 1 first of all we carried out an indepth study on the content of the most important tweets for each extraction the top10tweets ie the most frequent comments among those extracted were selected also taking into account the weight of views and retweets in the network the result is an indepth analysis of the main content posted by the networks hubs that is the users whose comments were most often viewed and commented on in turn the qualitative study at this stage allowed us to exclude some tweets as referred to specific or atypical issues and to select the main languages for each keywordperiod 2 then we focused on the analysis of relational structures employing network analysis tools this quantitative analysis is carried out on all comments extracted by applying network analysis this step made it possible to detect the eventual presence weight and quantity of actual parallel communities it is possible to potentially distinguish a stage of birth formation and decay of communities by considering the number of reciprocal ties selfloops unique ties and the presence of cohesive or noncohesive subgroups finding the presence of small groups and fragmentation of communication on several specific themes indicates a lack of cohesion and therefore of community while detecting large groups shows the structuring of discussions around strong arguments and or aggregation on thematic points the analysis is unrolled for each extraction in order to evaluate how the networks structure changes various considerations are possible with respect to the volatility of the relational and participatory structure including the aggregation and dispersion of a particularly large number of users on specific themes or moments this step allowed to selectfor each extractionthe communication structure and the main groups as subnets obtained by extracting clusters connected to each other with greater internal homogeneity and external heterogeneity in terms of links 3 finally the semantic analysis is applied to perform the automatic content analysis only main european languages are selected from the comments in the different european languages those of the most frequently used languages were selected this last stage shows differences and specificity on topics and discussions both at the level of languages and periods this kind of analysis allows to detect the main elementary contexts and themes for each language and to compare thematic clusters with respect to the different periods by progressively employing exploratory cooccurrence analysis extraction of elementary contexts identification of clusters of main lemmas and factorial analysis for each language and keyword the main users the first step of the analysis aims at highlighting the tweets emerged from each extraction this qualitative step is crucial to determine the networks hub as it is from them that users reaction will branch a deeper analysis of the main comments will be needed for a correct matching between the language and the related geographical area certainly the choice of the extraction keys is going to have an impact on both the structure and the content of the communication in this case extraction keys are hashtags and they are going to be weighted based on their frequency in the first extraction the chosen hashtag is nomask during this period five draws were carried out a close monitoring of the communication showed a high share of comments in italian english and french this first period goes through at least three specific moments of tension the first vaccine distribution the growing spread of the contagion and the decision of many governments to close shops restaurants and attractions in many parts of the world during the second period ranging from 1st march 2021 to 30th june 2021 governments measures weakened due to a contagion rate reduction in order to monitor the communication on twitter the chosen lemma is covid19 this generic extraction key has a high incidence of comments in asiatic languages and english in particular most of the comments appear in agreement with the need to impose limitations and restrictions last wave of extraction refers to the communication centered on the hashtag greenpass this is specifically characterized by a communication in italian language tending to contrast anticovid measures the almost exclusive presence of italian tweets depends on the hashtag selection greenpass in fact is chosen italian name to refer to a digital covid19 certificate named otherwise all over europe when not specifically named at all this preparatory stage of analysis as mentioned before shed light not only on comments and prevalent sentiments but it also gave other relevant information about users recipients and specific topics in particular nomask communication seems to be almost exclusively private and contestoriented in fact while it denotes a satirical approach against novax in italy it appears more centered on mobility protests and claims to freely purchase in english if british protests on twitter appear characterized by a form of liberalpopulism in france they seem to be the outcome of a more emotionalindividualistic approach suffice to think about the number of retweets a comment against mask usage in kindergartens had as was to be expected the comments drawn searching the lemma covid19 are more generic and cover different topics it emerges however a more positive reaction to controls and restrictions moreover this wave shows a marginal importance of novax and nomask claims andunlike the former wavecomments are posted not only by individuals but also by institutions like political parties trade unions associations and newspapers too hence it is possible to witness both institutional and noninstitutional comments equally addressed to political institutions and people the first mainly express dissent to shops openings against scientific advice social distancing and mandatory mask usage abolitions in other cases these comments tend to criticize the virus mismanagement in schools and prisons the second instead tend either to promote compliance with containment measures or contain general updates on the number of infections the availability of oxygen cylinders and beds in hospitals ie data institutional advices and solicitation to respect the rules in the opposite direction the third wave communication although coming mainly from private citizens is evidently made up of subjects with a high sense of political effectiveness and selfdirected largely oriented to reach and influence political institutions and decisionmakers as anticipated at the beginning of the paragraph this first descriptive step of the analysis aimed to identify information on geographical origins on the sources of comments and on the feelings that can be deduced from the type of users involved main topics and recipients overall it turns out that the main hubs are different for each selected hashtag the tweets about the hashtag nomask are almost exclusively managed by private individuals and constitute networks that are not very dynamic closed mostly focused on small groups with forms of communication very similar to those typically oriented by popular rumors these networks can be further divided into two clear exclusive categories the prorestrictive measures that use the hashtag for derisive or ironic purposes and the actual nomasks which are opposed to any form of freedom limitation the patterns of the communication change when the covid19 tweets are extracted in this wave neutral positions prevail and frequent is the reference to other themes other than the contagion containment policies the comments related to covid19 are more oriented to the claim of mismanagement or again to support the restriction measures the most noteworthy characteristic of this network however remains the fact that tweets are not only posted by private users but also by institutional actors finally the communication related to hashtag greenpass shows many typical traits in common with nomask communication its mainly politically oriented movements thatunlike the latterare localized in italy and in united kingdom therefore it seems to emerge a new phase with a participatory structure oriented to protest and raising from below but more polarized than the previous one figure top tweets distribution of hashtag for policy evaluations against the spread of infections figure the representative graphs about nomask covid and greenpass the structure of communication the choice of hashtags shed light on particular types of users target and communication aims at the same time it also affects the structure of communication for example it is possible to identify the presence of thematic groups or real communities figure 4 shows the graphs of communication network for each hashtag the first to the left is the one related to the keyword nomask it is possible to notice how communication is divided into two parallel communities with only two main components and a series of unconnected nodes by contrast the communication centered on the lemma covid19 appears divided into a large number of subgroups finally the greenpass communication seems to be in an intermediate position between the two with a high number of dense groups the hypothesis is that the more divisive a topic is the more likely it is that large groups with conflicting opinions will emerge the more general a topic is the less likely it is to observe polarized subgroups to better understand the diachronic dynamics underlying the structure of the groups and their communication the major network measurements were applied to the tweet analysis the first of these measurements is closeness centralitycalculated as the sum of reciprocals of the smallest distance between each node in formula c c g j1 d n i n j 1 where d is the distance among the ith node and all the other gth nodes so the closeness provides information on the presence of thematic groups the higher the closeness the higher the presence of compact communities sharing a specific topic on the other hand low levels of closeness suggest a communication with no specific focus and small groups which implies that most of the networks nodes rarely interact despite the closeness never reaches high values during the observed periods it is true that the highest values are recorded in the period in which the hashtag nomask was observed this would seem to be in line with what the graphs suggest during the nomask detection period in fact few distinct thematically polarized groups are observed by changing hashtags inserting a more general topic communication is pulverized into as many subgroups as possible subtopics a whole different speech deserves the greenpass hashtag as said it mainly concerns italy it is addressed to institutional actors and it was carried on at that time when the phenomenon was considered outdated it may not be a coincidence that in november and december there is a reversal of the closeness trend as consequence of debate resumption the second network measure employed in the analysis is centrality degree here used in standardized form centrality degree is obtained considering the number of linkages each node hasd on the total amount of possible linkages underneath the network in formula c ′ d d g 1 in the specific case centrality degree refers to the number of relations among nodes detected looking at the reactions to the tweet ie visualization retweet likes etc as it is possible to notice from figure 5 the degree shows a trend growing over time such an increase seems to be triggered by the specific topics observed and it reaches its acme when dealing with communication on greenpass the nomask communication does not appear centered on few particular nodes but as shown by the closeness it will generate few discussion groups containing very homogeneous nodes in thematic terms the low degree valuesin factsuggest a peer communication within groups and not centered on public users moving on to analyse the degree in covid19 communication there is a slight value increase compared to the previous period this could be due to the source nodes of this communication as observed in figure 1 in this period the debate is often generated by political and institutional actors whose visibility consequently triggers a greater chance of reaction both in terms of protest and in terms of inspiring the wish to go deeper the degree centrality reaches its peak in october when observing the network structures related to the third focus of the analysis the hashtag greenpass the high degree value in this case highlights the existence of a broad and open communicative dynamic in such a case communication does not only imply reactionswhich are still presentbut it becomes more direct creating an actual debate between private and public users which communicate with one another in the digital square and not in close subgroup as observed in the nomask network the third measure used in the analysis is the betweenness centrality it is obtained through the sum of all of the partial betweenness calculated for each couple of nodes in formula c b j k g jk g jk where g jk is the number of geodesics that connect two nodes containing a ith node betweenness centrality highlights the presence of users that play an intermediate role between either users or groups of users a high value of betweenness indicates an open communication network characterized by continuous exchanges between nodes and between subgroups on the other hand a low value of betweenness underlines the presence of closed groups not interested in communicative exchange with other groups the analysis of betweenness in nomask period confirms what has been previously noted in this case in fact the communicative structure seems sparser a sort of pseudodialogue among people sharing the same thoughts closed groups within which no nodes with intermediary roles are observed and reluctant to accept exchanges with other groups on the other hand communication in the following two periods appears more intense the presence of intermediaries emerges in fact when looking at the covid19 centered communications and becomes evident with greenpass centered discussions the involved nodes in this case not only participate by reacting to tweets but sharing them contributes to their dissemination and in some cases generates protest movements on the digital and real streets the main contents in order to analyse the content of the comments disseminated in the networks we optedfinallyto conduct an analysis on the main languages for each of the selected lemmas the structure of the communication is different depending on the lemma identified and the contents are not necessarily aligned highlighted dynamics and emerged points of view are very different depending on the reference context first of all the prevailing languages are not always the same if we restrict the analysis to european languages it emerges that most of the nomask comments are in english italian and french and those on covid19 are mainly in english and to a lesser extent spanish those centered on the word greenpass are however predominantly in italian the first analyzed lemma nomask mainly involves communication between private users that said the structure and content of communication are identified progressively moving from the analysis of associations between basic units of communication to the identification of clusters of main phrases the analysis of cooccurrences centered on the abstraction key allows us to detect some content specificities the meanings related to the keyword nomask for example change depending on the languages in italian there is a clear association with novax conspiracy but also with a series of terms used to ironize against the selfstyled nomask movement the french communication is deeply different the ironic element disappears and it is replaced by the emotive one particularly with respect to the limitations imposed on children and the reference to historical events traceable to wars and revolts the meaning of these associations is not always evident but becomes clear in the other phases of the analysis when phrases and comments emerge which are also traced back to precise links and references further specificities are noted with the analysis of the english comments where the content mainly concerns the dissent for the restrictions on freedom of movement in front of the social and relational events in which one would like to participate the liberal matrix of dissent is evident with protests about shop closures or against the ban on entry without a mask but also references to the assumed uselessness of these decisions these differences emerge more clearly when comparing the clusters of contents for each context this is possible thanks to the multiple correspondence analysis which applied to lexical content shows the association between main lemmas and periods and also the most repeated content so we identify the main clusters for comments in each main language the most numerous comments are the english ones the clusters obtained from the acm are three and are named as nomask scammers and workers the nomask group is formed between november and december when protests over freedom restrictions characterize communication in this group there are controversial comments against restrictions andor vaccines and opposes the cluster called workers referring to the protests against the limitations of work activities but also more generally to the closure of shopsmovements many of these comments refer to a video showing a woman being kicked out of a shop for refusing to wear a mask comments related to this cluster mostly from january are associated with protests about rules protocols and the impact on worklifeleisure this cluster is particularly numerous and includes both protests against the containment measuresregulations for workers and comments referring mainly to labor discipline in particular subsidies and business support finally the third cluster scammers consists of comments referring to fears of contagion and protests against public or private figures who violate the rules of distancing looking at italian comments the cluster named nomask concerns mainly comments of january and february here appear polemic messages against the restrictions and the use of dpi news and statistics supporting nomask thesis only frontiers in sociology frontiersinorg this little group actually support nomask movement the other two clusters are against nomask movement andor novax positions principe with ironical languages and political references and ordinanza referred to political scandals the misuse of public funds or real errors of assessment that caused increases in infections and number of deaths among frail elderly people the ironic component is the most frequent both against nomask movement and political personalities instead the comments in french shows a huge weight of emotional states the analysis shows three clusters of comments but the main thematic group named souffle is the most emotional one it is referred to limitations and distances imposed in schools and among children even in kindergartens the other relevant cluster is also the less numerous cluster is named numerique and it refers mainly to fake news on data about contagion and conspiracy hypotheses with inappropriate references to historical events as nazism and related limitations of quite different meaning and scope a further cluster named parler occurs mainly in february and it is not referred to pandemic crisis at all it includes mainly comments discussions and debates among young people referred to pop culture and japanese culture considering the second phase of the researchcentered on the word covid19 it has already been noted that these comments are very numerous and heterogeneous some of them also refer to protests against distancing measures these comments are however mostly in support of decisions aimed at reducing contagion restricting to european languages the most numerous tweets are predictably those in english they are followed however by those in spanish focusing on these two idioms typical contents of communicative clusters can be identified first of all analyzing the words in english the reference to health fears certainly emerges this is the prevailing content with respect to the proposed extraction juxtaposed with the different positions for and against vaccination and containment measures a reference strongly associated with the indian context which suffered many losses and had particular difficulties in managing the emergency the reference to india unlike other areas with similar problems is very much present on social media and as comments in english aimed to promote activities for the population a third area is about information and reference to statehood reference to vaccination and health protection concerns are also widely present in the comments in spanish which however refer to the local rather than the national dimension and to the level of reflection and respect for the person further information can emerge from the a on elementary contexts through which it is possible to distinguish four thematic clusters for each idiom in english the local cluster prevails which refers to local statistics on infection rates distributed throughout the territory reports and similar references and which is characteristic of may and july this is followed by the clusters hospital and vaccine which are of obvious interpretation and the cluster immigrants which refers to planned indications for the treatment of sick immigrants or limits on access quarantines or again to the risk that the presence of irregular immigrants causes an increase in contagions these comments vary widely in relation to the reference context from texas to canada the latter cluster is specific and isolated from the others and it is not present in any other analysis but only emergeswith this centralityin relation to the englishspeaking context looking at the cooccurrences the comments in spanish would rather seem to be mainly centered on concerns about contagion and on the issue of personal protection these comments are clustered in four groups called infection vaccine masks and normality the prevailing themes are thus clearly aligned with concerns about infection and the desire to resume a life considered normal this is followed by heterogeneous reflections on the vaccine and there are not significant clusters with protests toward regulations and controls finally the last stage of monitoring concerns the greenpass extraction key which is associated both with issues specifically linked to the italian polemical debate against restrictions institutional references and the desire of protect freedom these elements also emerge all of them from the multiple correspondence analysis this second procedure shows the multisemantic nature of the movement against compulsory certification which is particularly stringent in the italian context in fact six thematic clusters can be distinguished the cluster named job includes tweets that deal with practical issues such as access to workplaces with a certificate or the rights of the worker after the application of the covidpass obligation while the cluster named anger includes comments that complain about constraints and obligations using particularly aggressive language and proposing inappropriate parallels such as references to limitations of freedoms typical of dictatorial regimes or historically known references to war events and forms of xenophobia or genocide the novax cluster on the other hand refers above all to expressions of protest by those who do not want to be vaccinated another cluster identified can be considered related with this one and in named conspiracy this includes comments referring to alleged conspiracies aimed at imposing constraints and limitations for reasons completely unrelated to health risks seen as a nonexistent or overstated threat in order to impose behaviors political positions and uncomfortable decisions even of economic nature similar arguments but mainly centered on the protection of rights and freedoms characterize the fifth cluster named freedom which refers to topics particularly mentioned in august while the last cluster includes institutional references with references to politicians government and healthcare both in polemical and neutral terms overall communication is mainly centered on forms of protest and social and political disaffection clusters referring to the need to work the risk of economic crisis and political recriminations prevail in october while those referring to limitations as an unnecessary or unjustified constraint are present in summer it is interesting to note how this plethora of protests and even instrumental motivations are characteristic of a context that at the beginning of the extraction was rather critical of the nomask movement itself these are therefore two very different phases that drive positions and opinions decidedly far apart clusters with a strong polemical and emotional content are also the most numerous followed by those referring to economic and political motivations discussion the proposed work reconstructs the debate developed on the social network twitter and related to issues associated with the pandemic crisis several studies have recently focused on both reconstructing narratives and analyzing attitudes and behaviors arising from the particular emergency conditions in addition many works beyond the emergency plan and specific social political and economic reactions have dealt with the pros and cons associated with the spread of communication on social networks particularly with reference to the dissemination of distorted information and more specifically with regard to the risks of cognitive fallacy associated with a confirmation bias the paper traces the main theses and considerations that have emerged in reference to the widespread perception of the pandemic crisis and different modes of reaction identifying three specific interdependent topics the perception of risk and the construction of scapegoats reactions typically related to ontological insecurity and the emergence of reinforcing effects of fallacious reasoning dependent on unconscious overexposure to customized and catchy messages the latter dynamic in particular is studied with reference to the algorithmic management of communication on social media having posed these arguments the study seeks to reconstruct the main lines of argument of communication on social also identifying them with respect to the characterizing periods to this end rather than automatically referring to the overexposed arguments on social it was decided to identify the main extraction keys as a result of continuous monitoring of media communication but also of communication on social a second reason for the selection derives from the attempt to identify different forms of communication distinguishingspecificallythree of them nomask a strongly distorting communication with respect to the content of institutional and health information in particular characterizing a transnational collective movement and protest as ephemeral as it is lively in its expansion phase but destined to be shortlived comments on the social moreover present an ambiguous content with positions that are sometimes oriented to ridicule or irony rather than to support the ideas of reference covid19 this second communicative form characterized the entire emergency period and still remains significant on the web it mainly consists of comments supporting institutional and prudent messages or the institutional messages themselves oriented to inform and spread prudent practices greenpass a third communication structure is specifically prevalent in the italian context where control measures have been particularly incisive and longlasting even after the distribution of vaccines and therapies particularly at a time when there appears to be too much caution compared to other areas that have limited or eliminated forms of distancing and progressive closures communication on the issue becomes particularly tight and also produces offline forms of protest constituting real communities of discussion if not an actual protest movement the three conditions of online communication reflect in effect three phases of action and reaction to the pandemic threat alarm emergency and generalized restriction of activities protection of the population and institutionalization of the emergency and progressive return to normality and openness finally on the methodological level it is possible to identify some specific advantages of the threestep procedure proposed here which allows for the identification of messages and communications constitutive of comparison networks minimizing the noise that is always present when extracting information on big data the analysis is circular and open each step confirms elements that emerge from the others so you can modify the parameters when changes in the style and structure of communication occur specifically the extraction of the top10tweets allows an indepth analysis of a low number of relevant comments so we quickly identify errors problems and new topics the network analysis tools allows us to identify the structure of communities and how they change over time selecting the most important communities or discussions the differences among structures of information selfreference and communications the presence of hubs within the net etc the automatic content analysis on specific languages allows us to evaluate with attention the content of comments and the importance of each cluster comparing communication through main topics languages and periods finally we obtain the main information related with the structure of communications the main languages the main problems related to information andwhere appropriatethe symptoms of institutional disaffection or actual social protest it is therefore possible using this procedure to identify information indicators and narratives referable to political and social debates involving different categories of users identifying the main sources motives suggestions this practice could also be useful in acquiring information for implementing social policies or public decisions identifying problems or reshaping structure and content of messages and information for the population data availability statement the raw data supporting the conclusions of this article will be made available by the authors without undue reservation 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

this study focuses on the analysis of contacts and communications on twitter concerning pandemic policies the goal is both show mobilization processes rising from the web and detect main actors themes and contents within the european context through a mixed method procedure we tried to identify the main themes and most relevant communities the main users the most relevant topics and languages and the underlined meanings and di erences related to languages as proxies of areas monitoring the communication on main topics nomask covid greenpass we noticed the weight of the gap between the governments attempts to communicate information motivating measures geared toward managing the crisis and the perceptions of private users these perceptions spread through the web with such force the more the emotional ironic or polemical plane weighs in this sense online communication could be considered a tool for understanding the weight of the interaction between the institutional social and private dimensions with e ects on the social construction of identities digital communication is becoming an element of this process the paper describes the reassuring role played by the digital community in the construction of ontological forms of security resulting from the construction of a shared digital culture results show the emergence of digital communities structured on reference hubs and standing out from the detected phenomenon prevalence of idioms and even language structures the relevant role of the emotional french ironic italian protest english component is confirmed but also the changing and fluid structure of the debate and the copresence of many parallel discussion communities

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introduction children start using digital technologies at a young age in 2013 75 of american children under the age of nine used a tablet or smartphone in the home and by 2018 42 of 57 year olds and 47 of 811 year olds in the united kingdom owned their own personal tablet further despite the age limits of most popular social networking sites being 13 upwards in 2018 12 of 9year olds in the united kingdom reported using one or more social media sites rising to 34 by age 11 there are dangers involved in being online at a young age approximately 16 of 811 year olds and 31 of 1215 year olds in the united kingdom have reported seeing something inappropriate online and worryingly 22 of 1215 year olds in the united kingdom report being contacted by a stranger online evidence suggests that children have some limited perceptions of the dangers of going online for instance zhang kennedy et al reported that children aged seven to eleven articulated concerns about privacy threats seeing inappropriate content online and online strangers other research concurs that young children show awareness of both the risks and negative aspects of going online and the importance of cybersecurity including controlling and being aware of ones digital footprint in contrast young children can also report unfamiliarity with the concept of the internet implying low levels of awareness of its associated dangers thus childrens awareness of cyber security and online dangers is uneven with differences amongst children according to age gender and socioeconomic status further it is unclear to what extent childrens awareness of online risks translates into secure behaviors meaning further research is necessary to understand to what extent children are aware of the dangers of cybersecurity threats and their level of knowledge as to how to address them within the home we might assume that parents are naturally in charge of cybersecurity after all parents guide their children toward the most ageappropriate television programs to watch and video games to play and mediate their childrens use of the internet parenting styles in terms of patterns or combinations of parenting practices may influence the type of approach adopted by parents in their management of household cybersecurity baumrind described an influential typology of parenting styles in which parenting practices differ along dimensions of support psychological and behavioral control in this typology parenting styles are defined as authoritarian authoritative indulgent or permissive and neglectful these parenting styles have been supported both conceptually and empirically in relation to developmental outcomes for children general parenting style then may dictate the type of approach parents take to managing cyber security in the family however there is an argument that rather than parents being solely in charge of household cybersecurity children are becoming the leading experts in technology use in the household indeed children influence their parents particularly in encouraging them to take up social media and teaching them how to use new technology in the home such as computers and the internet so if children influence their parents in their use of new technology how does this relate to the management of cybersecurity within the home we propose that instead of parents being solely in charge perhaps the management of cybersecurity in the family home is negotiated between parents and their children prior research has examined such processes of negotiation in the context of technology use in the family home for instance there is evidence for conflict in parentchild relationships when parents try to restrict childrens use of technology like tablets this conflict is even more evident when children take the lead in technology use in the home as traditional power roles of parents versus their children are reversed however it is yet unclear if similar processes apply to the management of cyber security within the home it is possible yet unexplored that tensions could also characterize the negotiation of cybersecurity within the family home it is important that we understand this issue as if there are tensions between parents and children in the management of cybersecurity this could leave the whole household potentially vulnerable to cyberattacks pertinently the united kingdom government has recently made understanding how families manage cybersecurity a priority showing there is a research gap in this area thus we aim to increase our understanding of what parents and children in the united kingdom perceive as cybersecurity threats and how such threats are managed and negotiated within the family home given this is an exploratory area we take a qualitative approach to gather initial indications as to the types of cybersecurity threats that families in the united kingdom are concerned about and the negotiating processes within the family home in terms of managing these threats our initial findings will guide further larger scale examinations of the processes and factors involved in family negotiation in cyber security and inform knowledge as to how best to support families in their cybersecurity management we use the model of social change and human development developed by pinquart and silbereisen to frame our investigation into the negotiation of cybersecurity in families the model proposes that the effects of any social change upon individuals are mediated through microsystems or immediate personal contexts such as the workplace school and family wide scale social changes result in changes to these personal contexts placing demands on the individual as an example a wide scale economic crisis may result in job losses in the workplace placing financial demands upon an individual the model predicts that how individuals deal with these new demands such as trying new options or avoiding risks will depend on several factors these include the resources the individuals have available to them such as social support or individual knowledge and the factors that limit their ability to cope with new demands such as economic or social vulnerabilities thus individuals vary in the resources they can draw upon to deal with changes in their microsystems and individuals with relatively more rich sources of support are more likely to have a variety of coping responses that enable them to adapt to social changes both socially and psychologically in this study we apply the model to one particular social change the introduction and proliferation of new technology we use the framework provided by the model to explore how this social change impacts upon the management of security within the microsystem of the family home figure 1 presents the pinquart and silbereisen model adopted to highlight the proliferation of new technology in society as the social change of interest technology we use this model as a framework to structure our investigation into the ways in which cybersecurity is perceived and managed in families the model predicts that the effects of new technology being introduced into society upon individual parents and children are mediated through their use in the family home new technology being used in the family home places extra demands upon individual parents and their children in terms of managing the security implications of these new technologies according to the model how members of individual families respond to these demands in terms of their coping responses is influenced by the resources they have available to them and any perceived vulnerabilities these resources could take the form of individual level knowledge about cybersecurity or a social resource they can access such as a friend or workplace it professional who could provide advice the model also predicts that families evaluate the costs and benefits of adopting innovations in technology in terms of how much technology poses a risk to family security together a familys resources perceived vulnerabilities and perceptions of costs and benefits determine coping responses in terms of strategies families use to manage their security concerns in turn these predict the psychological technological and social outcomes of technology adoptions at the individual and society level given the exploratory nature of our study we took a qualitative approach to explore this framework in relation to how cyber security is perceived and negotiated within families in the united kingdom we conducted qualitative interviews with families with children between the ages of six and sixteen in the south west of the united kingdom to explore their views and experiences of managing cybersecurity within the family home we thus draw upon this framework to structure our research questions design the topics covered within the qualitative interviews and to guide thematic analysis of participants responses based on the elements in the model as described above and in figure 1 we formed the following research questions to guide our qualitative investigation rq1 what are the demands upon families in terms of the cybersecurity risks they are concerned about rq2 what resources do families draw upon to manage these demands and what vulnerabilities limit their response rq3 what are the costs and benefits of using new technology for families rq4 what are the coping responses that families use in terms of strategies to cope with the demands rq5 what are some of the social technological and psychological outcomes of the changes in technology adoption for families in the united kingdom materials and methods we advertised the study via local parenting groups and participant recruitment websites to families in the south west of the united kingdom who had children between the ages of 6 and 16 year olds living within the home resulting in thirteen families volunteering to take part we conducted facetoface semistructured interviews with these thirteen families with topics centered around our five research questions we explored the demands faced by families in terms of their main cybersecurity concerns what resources they draw on and vulnerabilities they perceive what families perceive to be the costs and benefits of using technology in the home the coping strategies they use to manage the demands and what the social technological and psychological outcomes are of managing these demands data was collected between october 2018 and april 2019 ethical considerations ethical approval for the study was granted by the social science research ethics committee of the university of bath united upon responding to the study advertisement and again before the start of the interview parents were provided with an information sheet and consent form which detailed the aims of the study and the topics that would be covered in the interviews children were provided with a child friendly version of this study information sheet and consent form after ensuring that both parents and children had read and understood the information sheet parents provided written consent to take part and consent for their children to take part children provided written assent to take part by writing their name on the childfriendly consent form interview procedure twentyone interviews took place in total in most cases one or both parents were interviewed first separately to their children followed by an interview with the children during the child interviews parents remained in the room or nearby in the house to maintain comfort for children the interviewer was flexible around the family schedule and wishes of the participants some children declined to participate and in these cases only parents were interviewed and in other cases parents and childrens interviews were combined as per the familys wishes similarly although most interviews were carried out in the family home some interviews took place in a suitable public space according to the wishes of the participants parent interviews lasted approximately 1 h whilst child interviews generally lasted 35 45 min according to the comfort level of the child the interviews were semistructured in nature with the use of a general topic guide but being sensitive to the topics that parents and children were interested in discussing within the area of technology use and concerns around cybersecurity interviews began with a general discussion of technology in the home what devices were used by family members and how frequently and how this is managed we report these details in table 1 when reporting devices present in the home participants tended to use the brand name here we report the type of device in order to compare across families that use different brands of the same technology the general topic guide was created to address our five research questions with topics centering around the elements within the theoretical framework guiding our study thus during interviews with parents the interviewer introduced discussions around what cybersecurity threats family members were concerned about and why what rules and guidelines were in the household around device and internet use and how they approached cybersecurity in the home discussions also included what social individual and community resources parents drew upon to manage cybersecurity and what families perceived to limit their ability to manage cyber security in the home the topic guide also included discussions around perceived positives and negatives aspects of using technology additionally the interviewer discussed how parents felt about managing cybersecurity in the home childrens interviews covered similar topics in a childfriendly manner depending on the age of the child images of various devices were used as prompts for children to discuss how they used technology in the home and the things they liked and disliked about using the technology and any strategies they used to limit any concerning aspects of using technology at the end of the interview families were debriefed and given a shopping voucher as a thank you for participating all interviews were audio recorded using a dictaphone the first author conducted all interviews thematic analysis the transcripts were transcribed verbatim by the first author who then coded all the transcripts we used thematic analysis as our method of qualitative analysis which is a method for identifying analyzing and reporting patterns within data we chose to use thematic analysis for its flexibility and ability to provide rich and detailed description of the patterns within our data the analysis proceeded following the steps outlined in braun and clarke transcripts were firstly read and reread to become familiar with the data before initial code generation capturing general repeated themes within the interviews these themes were iteratively reviewed and revised the first author conducted three rounds of coding before a final set of themes and subthemes were generated which were grouped around our five research questions relating to the demands faced by families in terms of cyber security threats resources drawn upon by families and perceived limitations the main benefits and costs to using technology in families coping responses utilized by families and finally wider themes around the social technological and psychological outcomes of using technology in the family all analysis was performed using nvivo software an initial codebook was created by the first author based on the final set of themes and subthemes which was reviewed by the second author along with a random selection of 20 of the transcripts this led to discussion and clarification on themes and one new subtheme being generated and revision of the codebook the first author then coded all transcripts using the updated codebook finally a random selection of 30 of the remaining transcripts were then reviewed and coded by the second author using the updated codebook intercoder reliability of all final major themes was acceptable with cohens kappa of68 with all disagreements resolved through discussion results table 2 presents a summary of the themes and subthemes generated in the interviews along with their prevalence below we describe each theme in terms of how they address our research questions each theme is illustrated with supporting quotes from participants we refer to our participants using a pseudonym followed by their gender and age rq1 what are the demands faced by families in terms of cybersecurity threats in this section we describe the cybersecurity threats that families discussed in the interviews cyberbullying stranger danger online privacy online content financial threats and technical threats cyberbullying six parents and six children expressed concerns about the negative impact upon emotional wellbeing caused by cyberbullying this bullying took several forms from comments made on social media to being harassed through group messaging apps lottie talked about how she was careful what she posted on her social media accounts as there are people out there who are not very nice and you could get hurt cyberbullying over and above more physical forms of bullying was perceived to have the potential for negative impact as it is always on meaning its impact can be longlasting and severe as described by this mother of 8 and 6 years old boys its high because it can have a big detrimental effect on kids the traditional bullying in the playground is almost easier to deal with if people are being pushed around its a physical thing that people can see and can understand but cyber bullying can happen in so many different ways and is very subtle and really influential to how someone is feeling some children echoed this feeling acknowledging how the always on stranger danger six parents discussed how their security concerns were based on the physical and emotional ramifications of their children interacting with strangers online and forming relationships with people that they had not actually met in person the media was quoted as a source of information about stranger danger as in this narrative from beth its the stranger danger purely aware of reading on the news about a teenager being murdered met someone from an online game concerns around online stranger danger covered a range of issues such as catfishing online grooming and cyber stalking as alison explained we are all very aware that it is real that children are groomed via the internet for exploitation this awareness or concern of the dangers of strangers on the internet was echoed by some of the children as explained by this 13 years old boy when discussing forming relationships online younger children in our study also showed awareness of online stranger danger as described by this 9year old girl is this catfish i know about this its where someone like say id said i was called lilly but then i actually go and meet them and im not lilly i think thats mean to other people online privacy privacy loss in terms of losing privacy due to posting personal information online was raised by six parents as a concern however four of these parents saw this loss of privacy as an inevitable part of digital life and not in itself constituting a cybersecurity concern as this parent stated she didnt think that the content she posted online posed any security risks this for me is medium to small if i put something on social media good luck to you i dont put much if i put a photo you are welcome thats the sort of thing so privacy not a problem contrarily these same parents often discussed privacy settings on social media as being an important aspect of family cybersecurity management all their settings are all on private they are not allowed any public instagram or whatever not allowed to be public only private settings thus there seemed to be a disconnect in the minds of some parents in our study between losing a sense of privacy by using social media but this not being a security concern and at the same time using privacy settings as a way of protecting family members online some children also raised online privacy as a concern and these children showed an understanding that posting information online could lead not only to a loss of privacy but could also constitute a security risk as articulated by this 9 years old girl then also dont put your like where you live your school your address all your information online because it then bullies and stuff can come over to your house and start killing you and stuff online content concerns about children encountering inappropriate content were mostly identified as a concern by parents of younger children one example was concerns around their children hearing inappropriate language younger children also expressed awareness of the potential for the internet to show them things they didnt want to see as observed by darren m age 7 google it can show you bad stuff it could show you really mean stuff or rude stuff financial scams included in this category are security threats which impact on the finances of the family such as identity theft phishing scams and scam calls raised by seven parents and four children interestingly parents who discussed financial threats described them as an inconvenience which lacked the ability to seriously impact on family life sarah said this about an experience of identity theft its a bit annoying and you feel a bit upset but it didnt impact us massively because we got the money back these parents felt that because they had experience in spotting scam emails or other scams that the threat level was low because they knew how to deal with them if its linked to like financial i dont really think im quite savvy about those so i dont see that as a big threat to me because i can spot them quite quickly in contrast four children expressed their concerns about the financial implications of identity theft in their eyes this means a loss of your financial security with potentially severe consequences charlie commented because as soon as someone has your credit card details they can pay for things log into your bank and thats it you are basically screwed technical threats seven parents highlighted that they were aware of technical threats those which concerned attacks on their devices which could result in data loss or loss of functionality such as viruses however these parents were generally less concerned about such threats referring to a trust in the technology itself to keep them protected from such things i mean ultimately they can be horrible referring to viruses that can do horrible things to your laptops and devices but you know apple is a fairly closed system and i trust that children did not raise any technical threats as a concern apart from one 12 years old boy who discussed the threat posed by phone hacking based on a prior negative experience they hacked my phone and they were sending very rude messages rq2 what resources do families draw on to manage these threats and what are their perceived vulnerabilities families had a range of resources that they drew on to manage the cybersecurity threats posed to their household we clustered these resources into two subthemes of family friends and trusted others and technological solutions in terms of vulnerabilities parents identified their own limitations in cybersecurity knowledge and both parents and children discussed insecure default settings on social media or websites family friends and trusted others seven parents identified friends family and trusted others as a valuable resource when they ran up against a problem with technology in the home be it functional or cybersecurity related their first port of call was asking others with perceived greater technological knowhow for help whether that be their friends family colleagues or a trusted brand im going to o2 because im thinking to myself i need to tighten down on their security for their sake but not knowing how to do it so thats my biggest challenge so i need outside help basically children described turning to adults for help if they encountered any threats or concerns online if it comes up with bad screen just go tell your adult and they will sort it out children also relied on emotional guidance from their parents including how to navigate friendships conducted online and how to avoid receiving negative comments on social media posts some parents relayed stories of providing emotional support to their children who were the victims of cyber bullying so parents provided not only technical support to younger children but had an important role in supporting their children in dealing with the emotional fallout of their usage of new communication technologies technological solutions some families described technological ways of protecting the family home some of these more technical than others depending on their level of expertise this parent for example had a background in it which he utilized to keep his family safe i do stick to a broadband provider that provides a number of things i specifically request the floating ip address that means its very difficult to actually find where our communications are coming from i ask for a broadband provider that has a builtin firewall with additional firewalls that we have on our equipment the technological solutions used by families included installing antivirus software on their devices such as mcafee or using devices specifically designed for children such as the leappad parents also chose to use parental settings or limits on devices as a technological way of ensuring ageappropriate content children were also aware of some ways in which they could utilize the protective qualities of the technology itself including childfriendly search engines some children described using the hectors world safety button in school which is a childactivated piece of software that children can use if they see something upsetting on screen using passcode locks on phones and devices was also mentioned by children as a safety measure one child was aware of keeping their device up to date as a way of protecting their game data limitations in cybersecurity knowledge six parents expressed the feeling that their technological knowledge was limited and this impacted their perceived ability to protect their children from encountering threats online instead having to rely on help from others some parents felt that the speed in which technology was evolving made it difficult for them to keep on top of the security implications my kids talk to me a lot about different stuff and i still dont think i can scratch the surface of everything that is out there and so how can i possibly keep up and assess the risk of everything insecure default settings some families also highlighted the difficulty of maintaining secure online practices when settings on social media and devices can leave them vulnerable to security and privacy violations unless explicitly changed this 13 years old boy discussed his difficulties in changing the default privacy settings on instagram its default public thats really bad i think they should change that i dont know about facebook and twitter but on instagram it was quite hard to find which surprised me similarly one family discussed how they felt forced into installing a particular piece of software on their gaming platform which left them feeling vulnerable to privacy violations when we bought him x box live because a lot of the games need it now we discovered with the connect joined up as well we could hear what was happening in peoples rooms there is a microphone and you can hear if they have obviously the same sort of thing you can hear what is going on in the background thus some families in our study expressed the feeling that their ability to control household cyber security was limited because of properties within the technology itself rq3 what are the costs and benefits of using new technology for families both parents and children discussed how the benefits and costs of using technology were constantly balanced some parents acknowledged the benefits of innovations in modern technology such as the internet in terms of easy access to knowledge and staying connected as a family some children were also perceptive in the advantages of using technology particularly for communicating with their peers its a good way of keeping in contact and its really easy and quick so thats mainly what i use my phone for the positive aspects of using technology were balanced out by its downsides which mainly consisted of the effects that technology can have on behavior charlie and sean both expressed concerns that they were becoming addicted to their phones and they were working to actively cut down their phone use this concern was echoed amongst parents whose rationale for having rules around access to and timing of device use frequently centered around their effects upon their childrens behavior not in terms of the potential for security breaches as observed by this mother of two they definitely dont get them through the week ever as you just lose them to the screen and they are like different children afterward thus although not a cyber security threat as such the negative effects of technology use on childrens behavior was frequently mentioned by parents as a reason why they limit their childrens access to technology there was an attitude amongst parents that spending time using technology even if it was safe and secure was not necessarily a good use of time rq4 what are the coping responses that families use in terms of strategies to cope with cybersecurity demands the strategies used by parents in coping with cybersecurity threats and managing cybersecurity within the household were clustered into three main subthemes of boundaries and rules monitoring and communication and education boundaries and rules many parents instigated a set of boundaries and rules around access to devices timing of use and which apps children can use or websites they can access these rules were initially introduced not for security reasons but with the hopes of minimizing any negative impact upon behavior so when we first got the tablets they were on it 247 and you can notice their behavior changes when they are on it too much such rules included the days of the week children were allowed to use devices and for how long parents often also controlled what apps younger children could download on their devices to ensure they were age appropriate using parental profile settings four parents reported changing their household rules to be more security oriented when their children received a smartphone upon starting secondary school at this point rules became focused on protecting children from harm they may encounter online one way of doing this was to create rules and boundaries around the type of content that children could share online as in the rules being described by this mother of a 12 years old boy we have rules about not being able to communicate with people he doesnt actually know if we are on holiday and we post pics we make them ambiguous so no one knows quite where we are or we post them once we are back when using social media children often described not sharing any identifying content by using initials instead of names or not sharing any personal information like phone numbers parents also made sure their children were aware it wasnt safe to communicate with strangers online whether that was on social media or when doing online gaming some children were aware of using passwords to protect their online accounts as described by this 12 years old boys strategy for creating what he felt was a secure password i use a secure password where i have had three previous passwords and i grab bits from all of them and mush them together many parents exerted boundaries around social media as a way of shielding children from the emotional impact of posting content online as explained by polly about why she was not allowing her young daughter to use social media anna wants a you tube channel but its all the negative stuff that goes along with it people commenting on it and controls you get they wont understand why people are being nasty other parents had rules about which social media platforms their children could access allowing some but not others for instance one 11yearold girl was permitted to join instagram and tiktok and to use whatsapp but not facebook due to the age restrictions on facebook accounts john planned to disallow his children from using social media when they were older boundaries therefore were designed to shield their children from the worst effects of using technology whether those are behavioral or protecting them from the dangers of interacting with strangers battling the boundaries against the background of these boundaries managing technology use and cybersecurity in the family home was often described by parents as a battleground children used devices or banned apps or games against the express wishes of their parents as told in this story by a mother of a 7year old who was playing an online game unbeknownst to his parents wed try to control what alfie has access to on the ipad so he only has access to what weve put on there but we found that he had access to whats that game fortnite or something because his cousin had downloaded it so the two boys had been secretly playing it at nannys house without anyone knowing about it you see reflecting the importance of peer relationships children fought against the limits imposed by their parents as to the apps and social media platforms they used daisy mother of a 14 and 7 years old told a story about her 14 years old son who installed a new messaging app to circumnavigate restrictions on social media i happened to pick up his tablet and words are coming up on his tablet and im like thats odd and it was a conversation he was having with somebody via this other media other children battled against security measures imposed by their parents as illustrated in this exchange between this mother and their child mother we use a fake birthdate thomas every now and then yeah mother we are supposed to be using a fake birthdate thus although parents instilled boundaries we noticed a tension between parents and children on this issue although children did seem to be aware of some of the potential for harm in going online as earlier illustrated these concerns did not deter them from breaking their parents boundaries and consequently potentially leaving the family vulnerable to security threats monitoring some parents managed cybersecurity by monitoring their childrens technology use for younger children this took place physically in that children were often kept in the same room when using devices for older children it took the form of virtual surveillance such as reading their childs text or instant messages sometimes this was done with the explicit consent and knowledge of the child and sometimes not in these cases parents might check their childrens phones but not necessarily with their explicit knowledge parents also followed their children on social media accounts so that they could monitor what they were posting online parents referred to such strategies as a way of unobtrusively ensuring the physical and emotional safety of their children when interacting online communication and education some parents managed cybersecurity in the family primarily via the relationships with children and educating them as to the potential dangers of going online rather than attempting to control their exposure or shielding them some parents combined this approach with other security strategies such as the use of technical solutions whilst others acknowledged the futile nature of trying to control what her children were exposed to online given its growing ubiquity rather they felt that educating and communicating with her children about what they were doing online was a more realistic approach as described by this mother of two teenage boys however many controls i put in the home if i limited if i blocked wifi if i limited anything from what they tell me about what happens at school they can see whatever they want whenever they want to so for me its more important about making them understand whats appropriate and whats not rq5 what are some of the social technological and psychological outcomes of the changes in technology adoption for families in the united kingdom in terms of the social technological and psychological outcomes of technology adoption for families throughout the interviews many parents spontaneously discussed their feelings about the challenges of parenting in the digital age we generated three themes to define these experiences described by parents parents discussed how they live in a whole new world ushered in by the proliferation of technology into family life and some parents chose to deliberately defer or avoid the use of technology in the home in response to this further some parents described the feeling that the challenges of parenting have not essentially changed apart from the new digital context modern parenting is a case of same same but different a whole new world some parents described the feeling that technology is developing and infiltrating family life too quickly for parents to keep up with sweeping their childrens development along with it it feels like things are happening earlier for our kids then for our generation i think technology has a lot to do with that for our kids they can talk to their friends in this very private secrets on their phones and its very different they live in a very different world parents also expressed their feelings that it is out of their control how much their children use technology and how it is now just the way of the world embedded in all aspects of modern life schools were highlighted as an influential institution both in playing a role in educating children around online safety but importantly influencing the age at which children were given their first smartphone this parent perceived that children at secondary school age were expected to have their own phone meaning parents have little choice but to ensure their children own one by the age of 11 the expectation is by the time they reach secondary school is that they have phones something wed rather not have started but yes we dont seem to have a choice anymore deferring or avoiding technology in the home parents of younger children sometimes articulated the desire to put the need for cybersecurity strategies off until a later stage although only appearing in 4 interviews this attitude played an important role in these parents approach toward cybersecurity these parents described their younger children as being naïve and innocent when it came to the internet using devices mainly to play games or watch videos as expressed by this father of a 7 years old boy to be perfectly honest i dont think he really knows the internet exists yet beyond an abstract concept the ipad for him it is a mini tv and games console and that is it really as such these parents expressed relief that they did not need to use any particular strategies to manage cyber security in the home instead choosing to defer these concerns until their children were older same same but different this final theme captures instances where parents presented the idea that they were living in a new world of technology but that the challenges of parenting are the same for example although parents were concerned about online stranger danger it is still the same stranger danger that their own parents had to deal with as highlighted beautifully by this parent we were told when we were young dont go into the woods because old whats his name is there and this is an extension of that and we are not treating our children any differently but its a much bigger wood one parent told the story of helping their child deal with an instance of chain letters appearing via a messaging app they explained that chain letters were present in their own childhood albeit in a different medium the method of dealing with them had remained the same he said i didnt want to send it and i told him you dont have to just delete it i said you dont need to carry it on nothing is going to happen they are still going on just changed how they do it similarly parents felt that their childrens battling against the cybersecurity boundaries was just another extension of normal teenage behavior i think its a bit like when we were kids youd go out and push your time for how long you are out so i think he was pushing to see what he could get away with in this way parents in our study expressed their feelings that parenting challenges remain the same as they ever were but advances in technology mean the context is different discussion we firstly discuss how our findings address our five research questions and illustrate ways in which technology adoption in wider society has filtered down to influence cybersecurity in the family home within the framework of the model of social change and human development within this theoretical framework the impact of the introduction of new technologies into society as a social change places increased demands on families both in terms of managing security within the home and the other social and emotional demands of family members using the technologies we highlight some of these increased demands in terms of the concerns that families have about cybersecurity amongst others families articulated a range of cybersecurity concerns from online content online strangers to financial threats similar to other research parental priorities around these threats were underlined by the potential ramifications for the physical and emotional safety of their children expressing greater concerns around cyberbullying online stranger danger and online content compared to financial or technical threats families draw on a variety of resources to manage these new demands these resources can be social or personal or could be using the security features embedded within the technology itself however parents also identified their own perceived limitations in technical knowledge or features of the technology itself as barriers to their ability to cope with the security demands of using technology within the home each family balances the benefits and costs of adopting technology within the home as illustrated in our participants discussions about the positive and negative aspects of the technology they are using all these aspects predict how families cope with the demands of adopting new technologies within the home in terms of which strategies they adopt in approaching cybersecurity in the family for instance some families instill rules and boundaries around acceptable online behavior and cyberrisks and some rely on communication between family members to manage security in the family we suggest that our final wider set of themes reflect potential social personal and technological outcomes families devise new ways of living because of the rapid development of technology and adoption into family life in terms of new rules and guidelines some parents seek to avoid the security and technological implications for as long as possible and some parents feel the speed in which technology develops means it is difficult to keep their children safe in the digital world how cyber security is managed in families we propose that the variations in coping responses and strategies adopted by parents in managing cybersecurity likely represents a combination of their perception of acceptable cyberrisk perceptions about the most effective ways of managing this risk and their parenting style in general although we did not explicitly measure or explore parenting styles in this exploratory study our findings could suggest that parents with a more authoritarian parenting style favor controlling the boundaries of acceptable cybersecurity activities and monitoring their childrens online activities as a method of keeping them safe in contrast authoritative parents may choose instead to rely on communicating and educating children as to potential dangers online supporting this idea parenting styles have been used to describe how parents mediate their childrens use of media in terms of autonomysupportive styles controlling and inconsistent styles we suggest general parenting style could thus be a strong influence over approaches to the challenge of managing cybersecurity in the family home future research should take a more indepth exploration of parenting style in relation to managing cyber security to address the question of why particular cybersecurity management strategies are preferred by parents over others further an interesting avenue for future research could be to use an assessment of parenting styles in a longitudinal study exploring how various strategies adopted by parents to manage cybersecurity relate to developmental outcomes such as the risky behaviors undertaken by teenagers in terms of cyber security negotiation of cybersecurity boundaries the boundaries of acceptable cybersecurity risk within the home and how these risks were managed were negotiated and renegotiated as children grew up in the digital world initially boundaries around when where and how children can use devices were often imposed by parents in order to control the risk of their young children accessing inappropriate content and minimizing the risk of any negative influences upon their behavior the restrictions around technology use by parents in our study is reflective of the parenting style termed restrictive mediation of childrens media use previously also found to be common in families with young children developmentally as children get older they become more focused upon their peer relationships and new media communication and technologies have now become a significant component of how these relationships are formed and maintained thus boundaries imposed by parents in our study became less focused on access to and time spent on devices and more around the types of information that can be communicated outside of the family and acceptable levels of risky activities these boundaries were renegotiated with the introduction of new technologies for instance a child may be allowed to use a new form of social media with the caveat that parents can monitor the posted content we noted several cases where parental rules and boundaries around cybersecurity in the home was associated with tensions between parents and children around access to devices allowable apps websites and social media platforms and privacy and security measures used by children our findings echo those around tensions in family technology use in other research reporting that parents trying to restrict device use for their children causes arguments and tensions in the home interestingly parents in our study were cognizant of the fact that these challenges and tensions between parents and children are the same as those of previous generations but the context is different as ever parents are trying to strike a balance between protecting their children versus allowing them their independence and privacy between maintaining boundaries for your children versus respecting their need to fit in with their peers these issues remain for parents these days but there is a new technologyoriented angle as now as well as wearing all the right clothes kids now need the right technology and social media presence in order to fit in with their peers further in line with views from academic research some parents expressed their understanding that young people in their desire to maintain nearconstant communication with their peers and breaking rules are not doing anything inherently different to what they always done it is just that the internet and social media have given them new ways of performing these actions thus when the issues of managing security in modern family households are considered in the broader social context of technology adoption these issues are arguably the same as they always have been the issues of trying to protect children from the dangers of the online world are the same issues that were present prior to the advent of the digital world further it is the parents perceptions of what are the most dangerous aspects of digital living which influence how much time and what their children are allowed to do online in the same way as parents perceptions of danger outside the house influences how much time children spend outside these ideas are echoed in the articulations of the parents in our study who feel that the fundamental challenges of parenting have not changed the context has merely evolved implications limitations and future directions as gatekeepers of their childrens use of technology and the internet all the parents we interviewed had a set of diverse strategies designed to keep their children safe online however there is a view that despite such strategies children are still at risk our findings are in line with this interpretation and suggest that families are potentially doubly exposed to cybersecurity threats sometimes from limitations in parental knowledge due to the rapidly evolving nature of technology and sometimes from their children pushing the parental boundaries of acceptable cybersecurity behaviors how can we improve this situation educating parents and children is one solution although increasing knowledge does not necessarily lead to less risky behaviors given the varying strategies adopted by parents in our study we suggest that a double pronged approach may be useful empowering parents to educate children in wider context free safety behaviors and also providing targeted assistance in specific technology based skills where parents feel this would be beneficial further a useful approach may be to encourage parents and children to view family cybersecurity as a joint responsibility rather than children fighting against their parents boundaries if they are included in setting the boundaries in the first place this may empower families to navigate the cybersecurity world together finally we acknowledge that there will be other local and wider influences upon the cybersecurity practices of parents and children that we did not capture such influences could include information from the media peers or the workplace how these external influences shape cybersecurity perceptions and management or could be leveraged to enhance cybersecurity within the family remains an avenue for future research this was exploratory work and as such provides opportunities for future research to build on our findings as well as address its shortcomings firstly future work should aim to explore cyber security management and negotiation in a larger and more diverse sample of households most parents we interviewed were mothers whereas most children were boys we acknowledge that this bias in our sample may have influenced our findings and interpretations around perspectives of technology use and preferred cybersecurity strategies future research in this area should include an equal number of male and female participants both parents and children to ensure that any diversity in perspectives related to gender or parental roles is captured further we also recommend conducting interviews across a greater geographical area to capture any differences in local and wider community resources which may impact on parents awareness of or implementation of cybersecurity strategies this would also entail a larger sample size compared to our exploratory study which would help to capture diversity and ensure findings are representative of families in the united kingdom relatedly in this exploratory study we did not explicitly consider how the age of the child impacts on their cybersecurity concerns management strategies or perceptions of technology however we acknowledge that the concerns and perceptions of children can alter as they progress through developmental stages and it is possible this applies to cybersecurity thus another interesting direction for future work would be to conduct indepth explorations with children at different ages to see how cybersecurity concerns change with age or developmental stages we acknowledge that using technology does not always equate to being skilled with technology and it is likely that digital literacy of parents and children influence how cybersecurity is managed within the family future studies should thus aim to include objective measures of the level of technological literacy of children and adults alike finally in this exploratory study we did not directly measure possible psychological outcomes of the management of cybersecurity in the home but these present exciting directions for future research conclusion in this paper we explored how families in the united kingdom manage cybersecurity within the family home we provide new knowledge around the demands facing modern families in their management of cybersecurity and highlight that the management of cyber security in family homes is an evolving process of negotiation between parents and children further parents in our study expressed the feeling that parenting in the digital age is a distinct and new challenge but at the same time managing family security is the same challenge it has always been in this way they felt that managing cybersecurity in the family home is a case of same same but different data availability statement the datasets generated for this study will not be made publicly available because the data consists of transcripts of interviews with parents and children and contain personally identifiable information requests to access the datasets should be directed to the corresponding author ethics statement the studies involving human participants were reviewed and approved by the social science research ethics committee of the university of bath united written informed consent to participate in this study was provided by the participants legal guardiannext of kin written informed consent was obtained from the individual and minor legal guardiannext of kin for the publication of any potentially identifiable images or data included in this manuscript 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

given the increasingly young age that children are using technology and accessing the internet and its associated risks it is important we understand how families manage and negotiate cybersecurity within the home we conducted an exploratory qualitative study with thirteen families 14 parents and 19 children in the southwest of the united kingdom about their main cybersecurity concerns and management strategies thematic analysis of the results revealed that families were concerned about cyberbullying online stranger danger privacy content financial scams and technical threats both parents and children drew on family friends and trusted others as resources and used a variety of strategies to manage these threats including rules and boundaries around technology using protective functions of technology communication and education around safety there were tensions between parents and children over boundaries potentially putting families at risk if children break household rules around cybersecurity finally parents expressed the feeling they were in a whole new world of cybersecurity threats and that positive and negative aspects of technology must be constantly balanced however parents also felt that the challenges in managing family security are the same ones that have always faced parents it is just that the context is now digital as well as physical

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aboriginal and torres strait islander peoples of australia are very sparsely represented in published genetic studies yet it is well recognized through these and from archaeological anthropological and linguistic evidence that they are one of the worlds longest living cultural groups having occupied the continent for at least 40000 to 50000 years the situation in which descendants of the first australians find themselves today as a minority in their own land is not unique yet of all the worlds indigenous peoples resistance to genetic research is possibly strongest this arises from many things possibly a combination of various circumstances within broader contexts a more recent colonial history within an age of accelerated technological advancement and even more recently proper recognition of their place in australia where societies at large experience increased politicization of human rights and social issues there are examples worldwide where researchers are able to work effectively with indigenous peoples taking time to understand the process that is required to achieve collaboration as one of these researchers i appeal to colleagues in the scientific community to appreciate the challenges and the pitfalls involved i also ask indigenous peoples especially those in positions of influence on committees and review boards to appreciate the structures and constraints under which scientists have to operate and to avoid increasing the bureaucratic complexity of monitoring research to a level that effectively results in exclusion from potentially beneficial involvement this is currently the case in many parts of australia the social impact of western science on all peoples has been profound technological advances have generated enormous power to affect people lives with clear advantages yet also many costs to cultural and social wellbeing over the last decades genetic technology has reached an unprecedented level of power to probe the origin and evolution of living organisms for indigenous peoples of the world who survive in environments that were changed forever by colonizing others extra challenges arise increasingly genetic researchers seek to describe and compare complete human genomes to understand diversity in living populations and from human remains of the past only by including indigenous peoples in these studies can the genetic history of our species be properly understood application of knowledge derived from these data is necessary to answer questions of ancestral evolutionary demographic medical and forensic relevance yet most aboriginal australians find it difficult to appreciate the value that such research might bring poor research practices of the past resulted in distrust that remains entrenched 1 2 3 even though salient lessons have been learnt from those mistakes by practicing researchers some responsibility for the lasting distrust of motives behind genetic studies arose from the presentation of the human genome diversity project in the 1990s to some aboriginal australian organizations it is so well remembered today that the experience and publicity that it generated is frequently raised and has harmed the efforts of many australian scientists who have worked hard with aboriginal organizations and individuals to present the benefits of genetic research to involve participants in projects and to deal together with the negative concerns 2 entrenched distrust is hard to overcome there are clear arguments in favor of describing genetic history of our species and scientists working in genetic research have for the most part proceeded with their work responsibly and with ethical integrity institutions and funding bodies have greatly improved their attention to the social impact of research yet very few individual scientists fully appreciate the situation of indigenous peoples in the world of today do not understand why resistance in australia is so strong and are poorly equipped to deal with expectations meet the challenges and develop partnerships the long history of human habitation in the island continent of australia known from archaeology linguistic and anthropological studies has been confirmed from several genetic studies most recently reviewed 4 and including several from my own research 5 6 7 8 they have created strong interest within the scientific community over the last decades many scientists outside australia have sought access to samples as the range of diversity within australia is not wellknown and many language groupsregions are not represented even for the participants of some published studies traditional links are unknown while requests for samples may have clear scientific validity appreciation of the situation for scientists working in australia is poorly understood by those making the request and do not seem to understand that samples cannot be sent outside the country without specific consent under current ethical guidelines and acceptable protocols this article discusses the pertinent example of the challenges facing both genetic researchers and descendants of the first australians in achieving partnerships that may realize the value of genetic research for all without creating social disharmony historical background the colonization experience is a familiar one for surviving indigenous peoples throughout the world lives for most are markedly affected by dispossession of culture language and traditional lifestyles after being forced to move aside to make room for largescale expansion dominated by technological political and economic power in new zealand the treaty of waitangi signed in 1840 exerted a powerful influence on subsequent colonial events though it did not stop the continuing process of dispossession native peoples of the americas suffered shameful exploitation by european colonizers and in many cases the lands subsequently ceded to them bore minimal resemblance to their traditional connections in africa europe and asia human demographic history has been marked by patterns of dispersal motivated by different needs ranging from changing circumstances such as climate economic needs population pressure conflict and the lust for power genetic researchers try to understand the genetic history of people today to answer questions related to biological and social wellbeing yet frequently fail to appreciate the concerns of indigenous peoples as a result of colonial history different world views and a struggle to retain identity an understanding of history is not only essential to facilitate interpretations of diversity population sizes in the past and geographic distribution of results from genetic studies on living people but is fundamental to principles of ethical conduct in australia the colonization period is recent and indigenous marginalization began immediately on the east coast extending rapidly into the interior with exploration and pastoralization 6 unlike aotearoa there has never been a treaty and in terms of the law land rights that are central to the identity of aboriginal australians have been achieved only since the 1970s 910 social history for the descendants of the first australians has been marked by dispossession appropriation of land separation of families and exploitation of women there is resultant resistance to research per se in particular to genetic research 1 2 3 11 and an increased effort to gain control through indigenous organizations at the local national and international level where australian aboriginal representatives sit on united nations advisory committees it is wellknown that many research practices in the early part of the 20th century had little regard for the impact on aboriginal australians after many years of negotiation the engagement of the australian government in current efforts to return those remains to traditional kin is beginning to heal some of the hurt 12 there is a place for genetic research in this process but the legacy of the past has meant that with some exceptions 1314 few aboriginal communities have agreed to the genetic study of ancient human tissue it is well documented that by the time european settlers arrived in 1788 the australian continent was entirely occupied by diverse and distinctive language groups under a doctrine of terra nullius that occupation was not legally recognized until 1992 15 from the early 1800s the forced relocation of whole families and the subsequent removal of children under assimilation policies sometimes to locations hundreds of kilometers from traditional country 16 meant that many living people with aboriginal ancestry are still unsure of their traditional connections in the changed circumstances of today communities live in scattered populations and there is considerable movement between cities rural and remote regions 17 while many aboriginal and torres strait islander people have overcome the social disadvantage of the past it is not so for many rural and remote communities where opportunities for training and employment are sparse with the emergence of land rights 9 aboriginal australians have made some gains in managing their own affairs establishing organizations that have some influence on policies albeit not as much control that they feel is their right for researchers this manifests as a wish for indigenous control over research projects that include aboriginal participants and in some cases hard fought funding has been lost due to delays or outright refusal to sanction nonindigenous involvement i summarize some of my own experiences and the processes currently in place in australia that scientists need to follow to work with aboriginal australian participation many of the principles behind these processes are those of fundamental human rights yet need to be seen in the context of colonization that has lead to social disadvantage for many peoples who have been colonized practice in the australian context my own experience began in 1992 when i sought aboriginal participation for a mitochondrial dna study and successfully obtained samples from people of the paakintji ngyembaa and mutthimutthi peoples of the darling river region in western new south wales my own background in nursing medical research anthropology and archaeology provided knowledge and experience for consultation and negotiation proceeding through the local land councils and participant families 3 consent was initially for mtdna analysis and later consent was obtained to do healthrelated genetic studies the mtdna analysis 5 6 7 identified strong and australian specific mt haplogroups now known as m42a s o p4b p8 which together with other studies have made a major contribution to knowledge of the matrilines in the region 4 already known to be a significant pleistocene habitat of the genetic studies with australian aboriginal participation that have been published my research is rare in being able to describe language group affiliation with accuracy yet this information is fundamental to interpretation of genetic results about the arrival and dispersal of people in the near oceanic region nuclear work was carried out on various single candidate loci and one genome analysis 8 however progress has been very slow lately during the last 20 years many community visits have been made by me and some colleagues to the region i have always visited organizations individuals and families providing reports maintaining good relationships and obtaining letters of support from various organizations however progress has been delayed lately due to increased requirements of ethics committees external to the local communities institutional ethics approval was given throughout by the university of sydney human ethics committee then university of new south wales human research ethics committee and state government health services since 2005 negotiations for ongoing research have proceeded through the aboriginal health and medical research council ethics committee of new south wales which was not in place at the beginning of my research but arose from efforts to establish aboriginal community controlled health services during the 1990s it is currently a requisite of the unswhrec to gain ethical approval from the ah mrcec before seeking institutional ethics approval for ongoing work that has been delayed due to the requirements of the ah mrcec that involve revision and reapproval of current consent forms renewed consent even for those that did so in 2011 the establishment of another reference group comprising aboriginal people with expertise in health and genetics organizational approval from the regional aboriginal community controlled health organization who have stated unwillingness to be involved but expressed the right of individuals to participate in addition delays are due to the lengthy documentation of 20 years of research which leads to apparent misreading of information previously supplied additional difficulties for myself have been in the form of incorrect assertions that have questioned my professional integrity presumably arising from uninformed sources external to the communities or families with whom i maintain very good relationships in a separate multidisciplinary project in northern australia the population genetics that was planned with my involvement as one component was vetoed by a regional land council despite community consent these delays are extraordinarily difficult yet i strongly believe that only by persevering will aboriginal and torres strait islander people realize that poor practices of the past do not continue in australia and truly engage in what can be beneficial work these experiences indicate that geneticists who wish to work with indigenous peoples need to be prepared to build relationships that recognize social issues around the physical and cultural survival of communities this must begin by contact either direct or indirectly through an experienced collaborator with an elder group or local leaders in the relevant community it is neither appropriate nor fair to ask national aboriginal leaders to act as a gobetween that contact must be made in a manner that indicates respect for the history and values of that community guidelines for appropriate research with indigenous peoples in canada 18 new zealand 19 as well as with aboriginal australians have been in place for some time 20 21 22 23 24 and are constantly being updated most relevant resources for geneticists because of the sensitivity to the use of dna are those that include guidelines for aboriginal and torres strait islanders who may wonder what they need to consider if asked to participate in research 25 the intrinsic values common to the guidelines and explained more fully in the document are that projects should be presented and negotiated with a spirit of integrity respect reciprocity parity recognition of survival and protection of social and cultural values a need for control and shared responsibility the essence of these guidelines for ethical research practice has been for the most part incorporated into submission guidelines for institutional ethics committees in australia ethical approval for specific projects needs to be sought from one or more appropriate ethics committees in institutions such as universities hospitals research centers or specific aboriginal organizations depending on the state or region forensic scientists collect samples for forensic purposes and reports that arise from these collections should have a forensic focus the use of the samples and the data that arise are restricted to forensic science in accordance with regulations that are not the same in all australian states the application of ethical principles in australia will vary as communities may be from remote areas rural towns with mixed populations or cities however the expectations will include appropriate engagement consultation and negotiation which will hopefully lead to participation a useful resource for researchers because it is also prepared for aboriginal and torres strait islander communities and individuals details eight steps with tasks for researchers 25 under the following headings building relationships conceptualization or thinking and planning developments and approval data collection and management analysis or looking at the meaning report writing dissemination learning from the experience the point about this general plan which may seem obvious to scientists is that researchers and participants have specific tasks and responsibilities at each step for the researchers and for funding bodies there is a clear need to invest resources into every step of the process and preparedness for personal engagement is essential with regard to dna research there are special issues related to consent custodianship of samples personal information and data dissemination these issues have formed the focus of discussions between geneticists medical and social scientists aboriginal people and ethics committee representatives over recent years and for the last 2 years at roundtable discussion groups hosted by the lowitja institute for which a freely downloadable document is available 2324 these documents are informative for researchers human research ethics committees normally work toward approval for a specific project and named personnel that have been submitted to the committee according to the particular institution any variation to the project or personnel requires additional consent from the relevant committee in genetic research this means that samples that remain from one study cannot be passed to other scientists or used for further studies with different aims without renewed consent it is counterproductive to the efforts of the many people who are involved directly or indirectly in negotiated research with aboriginal or torres strait islander people in australia if researchers outside australia proceed to use samples that were collected in another era it is expected that renewed consent to use those samples should be obtained the requirements of human research ethics committeesreview boards are to provide evidence from the research team that adequate care has been taken to follow the principals outlined in available guidelines this will include declarations that appropriate information has been supplied and that individuals have given consent on forms approved by the particular committee say for example the university of new south wales human research ethics committee where an additional ethics committee is involved such as the aboriginal health and medical research council ethics committee of new south wales there is an expectation that evidence of community consent to a project is in the form of a letter or document from the appropriate organization 22 this frequently raises the issue of whether community engagement means that communitiesorganizations want to give consent in the region in which i work the answer is no unresolved issues several of these have caused and are still causing great delays in my own work and in my view result in the foundering of beneficial partnerships between other geneticists and aboriginal and torres strait islander peoples control of research by aboriginal and torres strait islander people is understandable against the historical background that generated disadvantage yet it is interpreted to varying degrees in an increasing number of communities substantial direct involvement is in place especially for projects that have a direct impact on day to day life however for some aboriginal organizations or peak bodies control is expected to be more than involvement in a project for example the nsw ah mrcec advises that there should be aboriginal community control over all aspects of the proposed research including research design ownership of data data interpretation and publication of results 22 for some types of projects such as genetic research that require the use of expensive institutioncentered equipment technology and data analysis expertise a collaborative approach is necessary as none of us have the full range of expertise required very few aboriginal and torres strait islander people express interest in careers in science and to achieve the degree of control envisaged the available qualified aboriginal and torres strait islander people have to take on extra responsibilities to attract more people into research greater incentives in the form of scholarshipseducation and career opportunities need to be offered my own research has been criticized by the ah mrc because it has only involved communities and families by personal visits with constant feedback but has not had the resources to employ a community member as a part of the project this issue of control has prevented some welldesigned projects from eventuating community consent for a project is appropriate in many instances especially in a remote community where there is a central organization for example the research led by jenefer blackwell working with the wurundjeri people 23 p25 however there is great variation in response and sometimes one individual who is unwilling even to discuss a project reduces the confidence in others and results in a negative response in the area of western new south wales where my own research has been centered there is no single discreet community but people live in towns with mixed populations consultation and negotiation since 1992 has proceeded through several organizations such as wilcannia menindee and dareton local land councils wilcannia community working party community health centers elders of the mungo joint management advisory committee and maari ma health aboriginal corporation in all letters that i have received between 1992 and 2012 that give support in principle the organization does not give approval per se but recognizes and respects the right of individualsfamilies to continue participation this is in keeping with the united nations declaration of the rights of indigenous peoples 26 and the nh mrc guidelines 27 p10 that state that a community organisation or person has the right to say yes to be involved in research as well as having the right to say no how does this sit with the requirements of gatekeeping committees especially if they are comprised of people from a very broad region not necessarily including representatives from a local area should a negative decision override that of participants and their families community organizational consent may not be appropriate in all communities especially where there are internal conflicts between powerful families over identity or resources in my experience as long as trusting relationships are in place it is more acceptable to communities themselves to be asked to acknowledge that a research project has been negotiated and that the researchers are proceeding respectfully with willing individualsfamilies discomfort with the need for publication and the sharing of data even though it is anonymized is a frequent cause for delay clearly the focus of population biologists and forensic scientists cross paths here but under present guidelines it is difficult to collaborate in australia it is currently the reason why a recent publication using samples for which i remain custodian 8 has not made raw data files of a genome wide study available to other researchers the general fear is that data sharing might result in misuse and violate approval that has been given for specific studies for all parties this sets a limit on the value of results and is contrary to the academic principles that see the sharing of research outcomes as fundamental to the growth of scientific knowledge this point is highly relevant to the common interests shared by researchers in the current era of genome sequencing can projects really be presented as focused on a few specific questions even if there is trust between researchers and researched and the scale and purpose of a project is fully understood results of genome research offer the opportunity to interrogate the genome to answer different questions whether they be medicalhealth forensic or ancestryrelated questions restricted access databases that require a user to declare acceptance of the ethical principles underlying the consent process offer one way forward but no agreement has yet been reached to put this in place ancestryfocused genetic research is important to understand evolution of wellnessillness as well as history however for some it is seen as a threat to traditional belief systems it follows from impositions of other religions during colonization many aboriginal and torres strait islander people retain a strong traditional belief system combined with christianity and in the area in which i work accept the genetic results into their heritage acquired through archaeological and social science 6 aboriginal people from the strong language groups of the area are involved in archaeology management of the willandra world heritage area health housing and education and express interest in research including the genetic work there are for a few fears that genetic research might produce results that erode identity especially where colonization has imposed separation of families mixed partnerships and forced relocation this is expressed as a fear that native title claims might be threatened by genetic research there is no such requirement as part of the criteria for native title claimants 28 and it would not be appropriate as genetic connections of the past do not necessarily equate with the social and cultural connections that resulted in the language groups in specific country at the time of european occupation in summary my view is that geneticists should not be daunted by the complex process one is required to go through to include aboriginal and torres strait islanders in genetic studies there is currently no other choice but to build effective partnerships and broaden the dialogue with a goal of achieving beneficial outcomes for genetic researchers and researched to do this scientists have to be prepared to invest more than their expertise in genetics to work with aboriginal and torres strait islander peoples they need to build appropriate teams of personnel nurture relationships and develop better ways of communicating their intentions and the outcomes of research so that participants can see the benefits that might flow without infringing human rights they also need to be prepared for delays and possible refusal but only with perseverance and honesty will collaborative relationships be forged the message has to be clear that unlike practices of the past where indigenous peoples were patronisingly singled out as interestingly different the focus is to include and not to exclude them from what should be research that recognizes their survival resilience and the role of genetics in shaping wellness competing interests the author declares no competing interests authors information the author is currently a visiting research fellow in the school of biotechnology and biomolecular sciences at the university of new south wales sydney australia prior to 2005 research was conducted at the university of sydney australia formal studies included anthropology archaeology and genetics academic and research experience included australian aboriginal studies aboriginal health and education medical research nursing genetic research with aboriginal australians from the darling river region of western new south wales began in 1992 and included extensive ongoing consultation with the communities in the region ethical approval to continue work is currently being considered

aboriginal australians one of the worlds indigenous peoples now outnumbered through colonization are the most underrepresented in genetic research because they feel that the benefits do not outweigh the social cost of involvement descendants of the first australians have survived a period of european occupation during which time they were dispossessed of land language and cultural identity resulting in inequities in health education and employment opportunities compared to maori and native american peoples the ability to form organizations that help to control their affairs is very recent the desire to control is understandably strong yet the gatekeeping role of some organizations risks shifting the control away from smaller communities and has become increasingly politicized in the past research practices by western scientists were poorly presented and have resulted in resistance to proposals that are perceived to have no beneficial outcomes for participants in this age of advanced technological expertise in genetics benefits to all humanity are clear to those carrying out research projects yet not always to those being asked to participate presenting extra challenges excellent guidelines for ethical conduct in research are available to assist researchers prospective participants and ethics committees or review boards that approve and monitor procedures the essence of these guidelines are that research should be carried out with a spirit of integrity respect reciprocity parity recognition of survival and protection of social and cultural values a need for control and shared responsibility specific aboriginal organizations with which researchers need to work to negotiate partnerships vary within and between australian states and will always expect aboriginal personnel to be involved people experienced in the consultation process are necessary as part of a team by working patiently through lengthy negotiations with aboriginal australians scientists can achieve valuable results but failure to do so with respect and understanding will not yield hoped for outcomes my own experience working with communities in the darling river region of western new south wales has been an enriching and rewarding one with a long period of successful research lately delayed by increased expectation of monitoring and involvement at state level

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introduction analysing the relevance of family background characteristics to individuals levels of income is important to understand how individuals income is determined by factors beyond their responsibility and consequently the extent to which a society is able to guarantee equal opportunities for all this article aims to analyse the role family background characteristics play in shaping individuals income and its subsequent effect on inequalities in spanish regions for this purpose we get estimates of inequality for the spanish regions and compute the importance of family background characteristics to the observed levels of income additionally we analyse the differences in inequality levels between the spanish regions trying to disentangle the main drivers of the levels of inequality ensuring equal opportunities in a society would mean that all individuals are able to achieve a certain level of income regardless of the level of income wealth or education attained by their progenitors or any other circumstances beyond their own control the analysis of equal opportunities in economics has been popularised by roemer following the work of several authors whose contributions incorporate the idea of equal opportunities from different perspectives likewise educational inequalities and income inequalities are closely related for instance solga found that education could be a great equalizer for income inequality when accompanied with redistributive policies furthermore checchi and van de werfhorst find that inequality in the quality of education affects income inequality indicating that their results are to some extent consistent with human capital and functionalist theories which argue that education is rewarded because of the skills needed in the labor market so inequality in the quality of education is expected to affect income inequality more palmisano et al show that inequality of opportunity in education is strongly correlated with inequality of opportunity in income the research available in this regard for spain shows a strong relationship between the income and social class of the parent and the school performance of individuals although there are some works that analyse income inequalities and mobility in spain most of them study inequality before the year 2000 in this sense it is important to perform an analysis with a more recent period in order to have a more adequate picture of the current reality which will allow policy makers to carry out public policies that are more in line with current needs likewise the role of parental background in education has previously been analysed in several investigations in equality of opportunity it has been proved that parental education and parental occupation are two of the most relevant circumstances in shaping individual outcome in income moreover focusing on the spanish case found that parental education significantly affects individuals income our objective is to analyse how different educational and family background variables at regional level are related to the observed levels of inequality inequalities and educational achievements can experience great variations between regions in the spanish case this fact could be especially relevant and interesting due to several reasons there are significant income inequalities between regions the distribution of income growth among the population differs between regions and the education systems are different since the competencies in education are shared by the spanish regions and the central government resulting in differences in the educational systems across regions to this end the analyses carried out in this article try to answer two main questions to what extent are family background characteristics important in shaping inequalities and which are the main drivers of inequalities across regions we will consider inequalities in income and for this purpose we will use the disposable income of individuals as an outcome variable to measure both income inequality and inequality of opportunity taking into account that spanish regions are very different from one another one could expect to find different answers to these questions depending on the region in fact suárez álvarez and lópez menéndez showed the importance of the regional dimension for the analysis of inequalities and opportunities therefore we perform our analyses at regional level considering the seventeen spanish nutsii units likewise since the analysis is at the regional level it is important to note that there was no devolution of government responsibilities during the period under analysis the rest of the article is structured as follows section two presents the database and the variables used also providing some descriptive statistics section three shows the estimates of inequality and inequality of opportunity for the spanish regions and the contribution of different circumstances to the level of inequality of opportunity section four provides evidence on the main determinants of the different levels of inequality observed across regions with a focus on educational variables finally section five summarises the conclusions of the article database description the analyses performed in this article rely on the european survey of income and living conditions a survey that contains datasets at individual and household level furthermore data are classified by regionsin particular eu nutsii regions which correspond to the spanish autonomous communities they are first level political and administrative divisions and each one has its own organic laws known as statutes of autonomy which determine the powers they have they are also divided into provinces specifically in this article we use the eusilc surveys conducted in 2011 and 2019 which provide income variables referred to years 2010 and 2018 the use of these two surveys is particularly relevant since they include an adhoc module which incorporates variables regarding individuals family background our analysis is focused on the seventeen spanish autonomous communities and the sample is restricted to individuals aged twenty five to fifty nine years because parental background variables are only provided for individuals within this range of age the variables we use refer to individuals circumstances ie factors that are beyond individuals responsibility for this purpose we use variables regarding individuals family background when they were children the first is parental education which is constructed using the maximum level of education of both progenitors classified into three categories low if both progenitors have at maximum a degree of compulsory education medium if at least one progenitor has completed secondary education and high when at least one progenitor has completed tertiary education similarly we use the variable parental occupation which refers to the occupation of individuals progenitor when they were children this variable is also divided into three categories according to the isco08 jobs classification more specifically these three categories are low skilled when both parents work in elementary occupations medium skilled when at least one parent works in an occupation comprised in groups five to seven of the classification and high skilled if at least one progenitor works in a high skilled occupation 1 we also include the variable childhood financial difficulties which is a perceptionbased measure that considers respondents feeling about the financial situation of the family when the respondent is around fourteen years old it is divided into four categories badvery bad moderately bad moderately good and goodvery good the variables used as circumstances correspond to a period prior to the one for which the income of individuals is analysed these variables correspond to the childhood period of the individuals since the idea is that they provide an approximation of their social and family environment and that they are circumstancesthat is that they do not depend on the responsibility of the individuals and clearly individuals cannot occur to them due to situations that occurred during their childhood finally we include a variable referred to income which will be used to measure inequalitywe use the equivalised disposable income of households which is equivalised by considering the structure of each household specifically this variable is constructed according to the equivalence scale used by eusilc which is the organisation for economic cooperation and development modified scale e 1 05 n 14 1 03n 13 where n 14 is the number of household members who are over fourteen years and n 13 the number of members who are thirteen or younger the equivalised disposable income is considered a good proxy of the available income individuals have in addition this variable has been used in other studies with eusilc data referred to education and inequalitiessuch as brzezinski 2015marrero and rodríguez 2012palomino et al 2016suárez álvarez andlópez menéndez 2018b 2018a table 1 provides a summary of the descriptive statistics at the regional level and for the two years analysed 2011 and 2019 more specifically it shows the share of the population within each category of the abovementioned variables additionally table 1 shows the sample size for each region and year it can be noticed that in some regions the sample size is not very large the survey used provides weights to make the results representative nevertheless caution is advised when interpreting the results estimating inequality of opportunity this section is devoted to estimate income inequality and inequality of opportunity and to compute the contribution of the variables used to circumstances to iop with the aim of showing at what extent family background characteristics and other circumstances are affecting individuals performance in terms of income for this purpose in addition to estimating income inequality we compute inequality of opportunity for the spanish regions and then we analyse the contribution of the variables used as circumstances to this indicator the basis of the study of iop can be found in roemer and yitzhaki and schechtman later on roemer formalise this concept and distinguish between circumstances understood as factors beyond individuals control and efforts that can be attributed to individuals performance and commitment in this context the analysis of iop tries to compute the part of inequality due to the first kind of factors in which parental background characteristics are included to know the effect that parental background characteristics have in inequality and more specifically in inequality of opportunity we estimate the indices of both sorts of inequalities for each of the seventeen spanish regions analysed before computing the contribution of these characteristics firstly to estimate iop in addition to previous variables referring to individuals family background we include two more variables regarding individuals personal circumstances in order to obtain reliable estimates and reduce the omitted variables bias these two variables are gender with two categories female and male and country of birth with two categories foreignborn persons and spanishborn to estimate iop we use the ex ante parametric method although there are many other alternative methodologies we have decided to use the exante parametric method since this is the most widely used procedure in the iop literature and thus allows comparability with other studies furthermore this method has the additional advantage that it does not require including information referred to the level of effort in order to compute iop we divide individuals into types t being each type formed by individuals that share the same categories of each circumstantial variable in our case we have five variables parental education parental occupation childhood financial difficulties gender and country of birth with three three four two and two categories each thus leading to a total of 144 different types of individuals these are the variables considered to be beyond individuals responsibility and therefore treated as circumstances then we estimate individual incomes following the expression lny i c i β u i where c i denotes the different variables used as circumstances and β represents the effect these circumstances have on income once the equation is estimated we get the fitted values μi exp c i β which are a counterfactual distribution of income that depends only on the circumstances the inequality of opportunity indices can then be obtained in absolute and relative terms quite straightforward iop a i μi and io pr i μi i y table 2 shows the results of both income inequality and iop in the equivalised disposable income through two indices the gini and the ge we use the gini index due to its easy interpretation and because it is widely used to measure inequality generalised entropy ge is also computed since this is the only measure with a pathindependent decomposition using the arithmetic mean as reference and can be easily used to compute the contribution of the circumstances to iop according to the obtained results northwestern regions and also two central regions experienced an increase in both income inequality and iop whilst for the remaining regions we observe a decrease in both inequalities with the exception of castile and leon and castillala mancha for which we observe an increase likewise in most regions we can see an increase in relative iop that is to say the share of inequality of opportunity in overall inequality increases and consequently factors that are beyond individuals responsibility become more important in shaping individuals´wellbeing and performance to answer our question to what extent are family background characteristics important in shaping inequalities once we get the estimates of iop we estimate the contribution of the circumstances and pay attention to the amount of iop due to parental education and parental occupation to this end we decompose iop using the shapley value procedure and we compute the marginal effects each variable has in iop in terms of the ge index table 3 shows the average contribution of family background characteristics to iop these circumstances are of great relevance in shaping inequalities the three of them account for about half or more of the total iop the exceptions are four regions of the northeast where the relative importance of family background characteristics is lower as it can be seen in this section both inequalities income inequality and inequality of opportunity both in levels and evolution differ between regions additionally the importance of family background characteristics to determine the levels of inequality of opportunity also varies greatly for this reason it is relevant to analyse the determinants of these regional differences drivers of inequalities the aim of this section is to know which are the main drivers of the observed inequalities across regions we analyse the reasons behind the differences in inequality levels between regions and how these differences can be reduced as a first step we look at the association between inequality levels and several variables we analyse the correlations between inequality variables and potential determinants of inequality we include economic demographic and educational variables table 4 shows the pairwise correlations it can be seen that as expected both sorts of inequality are positively and strongly correlated as figure 1 also illustrates regarding the economic variables included income inequality is positively and significantly correlated with the unemployment rate therefore those regions with higher rates of unemployment also suffer from higher levels of income inequality nevertheless its effect on iop is not significant the other economic variables included are the per capita gross domestic product the average wage the wage of the tenth percentile and the wage of the ninetieth percentile the gdppc the average wage and the wage of the 10 th percentile are negatively correlated with income inequality and positively correlated with iop whilst the wage of the the role of family background and education in shaping inequalities ninetieth percentiles is positively correlated with both sorts of inequalities nonetheless these correlations are weak and nonsignificant with regard to demographic variables we include the share of population over sixty five years and the dependency rate both variables are negatively correlated with the levels of inequality moreover the correlation between the population shares over sixty five years and the inequality variables is quite strong and significant as can be also seen in figure 2 it implies that regions with aged population have less inequalities possibly because retirement benefits an equalising effect on income we also include the net interregional migration rate but its correlation with inequality is weak and not significant educational variables seem to have the highest levels of correlation with inequality variables as educational variables we include five variables at regional level the first of them is the share of individuals with tertiary education which is negatively correlated with both income inequality and iop although this correlation is not significant then the educational dropout rate 2 which is positively and significantly correlated with income inequality and the success rate of highsecondary school which is negatively and significantly correlated with income inequality the two educational variables that show the highest level of correlation with the inequality variables are the average studentteacher ratio and the education expenditure per student 3 the studentsteacher ratio correlation implies that the higher the average number of students per teacher the higher the levels of inequality and iop additionally the correlation between the education expenditure per student and the inequality variables shows that the greater the education expenditure the lower the inequality levels this relationship is also illustrated by figure 3 these results show that there is a significant association between the levels of inequality and educational resource endowments both economic and human capital it is observed that those regions with a greater endowment of educational resource exhibit lower levels of inequality in addition to the pairwise correlations we perform several regressions to see if the previously observed associations also entail causal relationships table 5 shows the results of the regressionsas expected not all positive and significant pairwise correlations are significant in the regression analysis moreover regression results are not robust when comparing fixed effects and pooled ordinary least squares still the regression analysis shows that an increase in unemployment rate would cause an increase in the levels of income inequality additionally the expenditure on education is significant to explain iop showing that an increase in education expenditure would reduce inequality of opportunity summarising the analysis carried out in this section highlights the great relevance of education in reducing inequalities especially the expenditure on education and the number of teachers conclusions throughout this article we show the relevance of family background characteristics in shaping individuals income and the determinants of regional differences in levels of both income inequality and inequality of opportunity we wonder if familiar background characteristics have an impact on individuals disposable income to test that we compute inequality and iop indices for the different regions our analysis reveals that family background has a great impact on individuals income and it is a crucial source of unequal opportunities moreover this analysis reveals that for the spanish regions familiar background characteristicsin particular parental education parental occupation and the financial situation during childhoodare of great importance in shaping individuals performance and opportunities of achieving a certain level of income additionally we analyse the main drivers of the regional differences in income inequality and iop finding that educational variables are highly associated to inequality levels moreover the regression analysis shows that there is a causal relation between educational resource endowments and both income inequality and iopthe analysis shows that regions that invest more in education experienced lower levels of inequality the obtained results suggest that different regional education policies reflected in differences in expenditure per student are an important determinant of regional inequalities especially of inequalities of opportunity which are the sort of inequalities beyond individuals responsibilities and therefore considered unfair consequently some policy implications can be drawn from this empirical evidence the results seem to indicate that an increase in social expenditures could have an equalising effect on income in this sense it is important to mention the work from quiñonez who found that in the case of latin america social spending increases are associated with reduced levels of income inequality he distinguishes four areas of social expending and shows that each of them has different effects on income inequality additionally ellison and fenger show that the implementation of socially equitable and effective state policies or interventions depends on a thorough prior analysis of the relationship between labour market structures inequality social investment and social protection in specific contexts this underlines the importance of specific policies that can directly and effectively address existing inequalities and specifically target the groups that need them it is important when designing public policies to carry out analyses that clearly identify those individuals or groups susceptible to being targeted by the policies the analysis carried out in this article has allowed us to determine which are the most vulnerable groups and which are more likely to receive lower income and be therefore in a position of material disadvantage these are individuals from disadvantaged family backgrounds with parents who have a low level of education and who work in lowskilled occupations therefore it would be advisable to implement public policies targeting this vulnerable group additionally given that this research shows that the greater the educational resource endowments the lower the levels of income inequality it would be advisable to combine specific policies for vulnerable groups with policies aimed to increase educational resources more specifically redistributive policies could be combined with policies aimed at improving the quality of education and guaranteeing access to education regardless of socioeconomic factors and family background to sum up policies aimed at levelling the playing field seem to be necessary in order to improve the situation of those individuals who suffer a lack of opportunities in both educational and economic dimensions and who are more vulnerable to economic shocks data availability statement the data that support the findings of this study are available from the corresponding authors upon reasonable request competing interests to report notes 1 groups 1 to 4 are 1 managers 2 professionals 3 technicians and associate professionals and 4 clerical support workers groups 5 to 7 are 5 services and sales workers 6 skilled agricultural forestry and fishery workers 7 craft and related trades workers groups 8 and 9 are 8 plan and machine operators and assemblers and 9 elementary occupations this classification is made by the international labour organization 2 share of population aged 1824 who have not completed upper secondary education and are not in any form f education or training 3 both are referred to nonuniversity education

family background characteristics and educational resources are crucial in shaping individuals income and therefore a potential source of income inequality and inequality of opportunity this article analyses inequalities in the spanish diverse regions using data from the european survey of income and living conditions eusilc along this article we analyse the relevance of family background characteristics in shaping individuals opportunities as well as the role education plays in income inequality our findings show that family background characteristics are of great importance in shaping individuals performance and opportunities of achieving a certain level of income wellbeing and education also educational variables at regional level such as the education expenditure per student are highly correlated to the levels of inequality in view of the results it would be advisable to implement public policies targeting vulnerable groups to ensure equal opportunities and invest in education given its potential as equalizer of income inequality

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background family planning use in west africa lags behind other regions of the world with an average of 153 of married women age 1549 years using any form of contraception 1 in recognition of the need to improve fp use across the region in 2011 the ouagadougou partnership created an alliance of francophone african countries to work together to strengthen programs and accelerate progress towards meeting fp and reproductive health goals 2 senegal a member of the ouagadougou partnership made commitments to the family planning 2020 initiative thus demonstrating highlevel support for fp these commitments included the launch of a national plan for fp in 2012 increases in the budget allocation for fp activities the national launch of the informed push model to eliminate stockouts of contraceptives and supplies and an investment in demand generation activities nationwide 3 as a result senegal has made important progress in meeting its fp goals the 2014 demographic and health survey estimated a contraceptive prevalence rate of 222 up from 131 in 201011 almost a 10percentage point increase in four years 1 at the global level fp2020 aims to reach 120 million additional women and adolescents with fp services by the year 2020 4 the nine ouagadougou partnership countries aim to contribute at least 22 million additional users within the same time frame 2 the focus on additional users rather than new users or first time users underscores the need for fp programs to ensure that clients have continued access to contraceptive methods and services so that new adopters remain users for as long as they want to delay or avoid pregnancy 5 the importance of supporting continued use was shown in an analysis of data from 34 countries which estimated that 38 of women with unmet need were prior method users who discontinued for one reason or another 6 another analysis of data from 36 countries found that about onethird of unintended recent births were attributable to contraceptive discontinuation 7 actual discontinuation rates vary by country and by method a comprehensive analysis of dhs data from 25 countries conducted between 1990 and 2009 found the allmethod discontinuation rate to be 38 within the first year of use and 55 by the second year 8 earlier work from eight countries found a range of allmethod discontinuation rates within the first year of use between 18 and 63 9 discontinuation rates tend to be lower for longacting methods such as the intrauterine device and higher for shortacting methods such as the pill injectable and condoms for example first year discontinuation rates were shown to vary from a low of 13 for the iud to a high of 50 for the condom 8 these earlier studies did not include implants a longterm method that is gaining in popularity and has very low discontinuation rates ranging from 4 to 22 for the first year 10 nor have these earlier studies included data from senegal given that close to half of senegals total population lives in urban areas and that the urban population is growing at 36 annually it is important to consider issues related to contraceptive adoption and continuation in urban populations in the country 11 further while there is generally greater access to health facilities in cities than in rural areas this urban advantage may not be found among all residents 1213 in particular urban poor women may lack access to information and services and may have discontinuation rates that are higher than their wealthier counterparts this study used data from a large urban sample in senegal to examine womens discontinuation rates and patterns and the demographic factors associated with method switching the specific objectives of this analysis were to calculate overall and methodspecific discontinuation rates examine reasons given for discontinuation and assess characteristics associated with subsequent contraceptive switching and abandonment among women living in six urban areas of senegal methods the data for this analysis were collected by the measurement learning evaluation project as part of the evaluation of the urban reproductive health initiative in senegal a bill melinda gates foundationfunded initiative to increase the use of modern contraceptive methods especially in disadvantaged urban populations data were collected by facetoface interview from 6927 women in 2015 as the third round of a panel study women were aged 1549 years at baseline and living in the urban areas of dakar pikine guédiawaye mbao kaolack and mbour these cities were selected for intervention by the senegal urban reproductive health initiative called the initiative sénégalaise de santé urbaine and may not represent urban senegal overall half of the sampling units were located in poor areas and half were located in nonpoor areas the definition of poornonpoor was based on a participatory rating process conducted with municipal level administrative staff and other leaders questions were asked across the five dimensions of the unhabitat definition of slums 14 all study procedures were approved by the comité national dethique pour la recherche en santé through the ministry of health in senegal and by the institutional review board of at the university of north carolina at chapel hill information on contraceptive use and discontinuation for the five years preceding the 2015 survey were recorded in a monthly calendar similar to what is used in the dhs the calendar captured monthbymonth data on contraceptive use nonuse source of method discontinuation reason for discontinuation pregnancy birth pregnancy terminations and whether marriedliving with a man contraceptive methods recorded in the calendar included sterilization implant iud injectable daily pill condom lactational amenorrhea method other modern and traditional methods source of contraceptive method was assessed for each contraceptive event marital union was assessed at the end of each event the survey questionnaire collected information on sociodemographic characteristics such as age education parity city of residence and household wealth for this analysis womens characteristics were coded as categorical variables age education parity city household wealth wealth was calculated using a similar method as dhs using principal components methods 15 single decrement life tables were used to calculate allreason and methodspecific discontinuation rates at 6 12 18 and 24 months among women who started an episode of use during the calendar period an episode of use was defined as a continuous period of contraceptive use an event which can start or stop an episode of use or nonuse was defined as any status captured by the calendar including contraceptive use nonuse pregnancy birth or pregnancy termination an event could be as short as one month or as long as the whole calendar period no censor period was used further descriptive analyses were conducted for women who discontinued use of a method at least once during the calendar period for these women we examined reasons for discontinuation and method switching in the month after discontinuation reason for discontinuation was categorized as reduced need method problem method failurebecame pregnant while using husband disapproved supply and othermissingfatalisticdont know a status of next event variable was constructed based on the calendar month following the discontinuation and was coded as no need when no method was started and the reason for discontinuation was wanting to become pregnant actual pregnancy menopause infrequent sex or marital dissolution in need was the classification when no method was started and any other reason for discontinuation was given method switch was the classification for discontinuations followed by the start of any method in the month following the discontinuation a multinomial logistic regression was then used to estimate the likelihood of in need no need or method switch status after discontinuation by womens sociodemographic characteristics the method discontinued and the source of method discontinued methods discontinued were categorized as daily pill injectable implantiud other modern or traditional for the regression analysis relative risk ratios were interpreted for the predictor variables with statistical significance indicated at p 005 regression analyses were adjusted for clustering analyses were run using stata 141 the descriptive analyses were weighted for survey design reported percentages reflect the weighting discontinuation rates and number of observations are presented as unweighted results characteristics of the women included in the survey are shown in table 1 women included in the 2015 mle endline longitudinal survey were generally older than a representative urban sample due to the longitudinal design more than half of the women were age 30 or older while only 39 were in the youngest age category most women had received some education though only 372 had attained some secondary or higher level the number of children ever born ranged from 0 to 14 a solid proportion of the sample 349 had not had any children the highest percentage of women in the sample lived in dakar residency in mbao was also common the other four cities together accounted for 359 of women of the 6927 women included in the survey 608 did not use any contraception during the calendar period 114 used contraception and did not have any discontinuations and 278 used contraception and had at least one discontinuation the fiveyear calendar captured a total of 26022 events for these women these events included 5153 pregnancies 598 abortions miscarriages and stillbirths 4334 births 4511 contraceptive episodes and 11436 episodes of nonuse women were married or in union at the end of 898 of events of the 4511 contraceptive episodes the most common methods used were injectables daily pill implants and condoms there was a total of 2678 discontinuations the number of events per woman are shown in table 1 under calendar events almost 43 of women had at least one birth during the period of the calendar 135 had two three or four births 72 of women experienced at least one pregnancy termination the number of discontinuations per woman ranged between 0 and 8 overall the mean number of discontinuations per woman was 04 among women who discontinued at least once during the calendar period the mean number of discontinuations was 14 the allmethod and methodspecific discontinuation rate at 6 12 18 and 24 months is shown in table 2 the 12month discontinuation rate for all methods was 347 and increased to 537 by 24 months implants had the lowest oneyear discontinuation rates followed by the iud by definition all lam users discontinued by 12 months since lam is only a method for the first six months postpartum other modern methods though contributing a very small number of episodes also had a very high rate of discontinuation this is likely due to the emergency pill which is not typically viewed as a continuoususe method and thus only reported in the month of use of the commonly used shortterm methods the 12month discontinuation rate for daily pills was 38 for injectables was 327 and for condoms was 629 table 3 presents the reasons for discontinuation by method of the 2678 discontinuations the most common reasons given by women included reduced need and method failurebecame pregnant while using a total of 144 of discontinuations were due to husband disapproval other missingdont know or supply unlike the other contraceptive methods shown discontinuations of the iud were more likely to be due to a method problem than any other reason method failures were most likely to occur with traditional methods condoms or the daily pill husband disapproval was given as a reason for discontinuation most often with condoms as shown in table 4 most discontinuations were not followed by a method switch in the month following the discontinuation 694 were followed by nonuse and 133 were followed by a pregnancy only 17 of discontinuations were followed by use of another method in general daily pills were the most common method used after discontinuation followed by injectables either the implant or iud were used after 32 of discontinuations when the next event was method use discontinuations of long acting methods were most likely followed by use of short term methods such as injectables and daily pills pregnancy was highest after discontinuation of traditional methods and the daily pill the next event after discontinuation was also assessed for the subgroup of discontinuations that were not due to reduced need a similar pattern to that presented in table 4 was found though switching was more common and pregnancy was highest after discontinuation of condoms and traditional methods in total 512 discontinuations were followed by a method switch 1452 discontinuations were followed by nonuse and were also classified as no need for contraception based on the reason given for the discontinuation finally 709 discontinuations were followed by nonuse and were classified as in need of contraception based on the reason given for discontinuation results from a multinomial logistic regression of the relative risk of being in need relative to no need and in need relative to method switch illuminated several interesting patterns as seen in table 5 the relative risk of discontinuation for married women was 75 more likely to result in a status of no need for contraception versus in need compared to unmarried women being age 3539 years had a similar effect whereas parity of one or more and residence in mbour urban area were associated with a lower likelihood of being no need versus in need compared to the daily pill discontinuations of injectables implants or other modern methods were less likely to result in no need than in need likewise compared to pharmacies as a method source for the discontinued method discontinuations of methods obtained from public private or other sources are less likely to result in no need compared to in need fewer variables showed statistical significance in the comparison of method switching after discontinuation to being in need the relative risk for switching methods was significantly lower for women living in mbao however women with any formal education were more than 50 more likely to switch methods than remain in need of contraception after discontinuation than women with no education or koraniconly education the likelihood of switching compared to being in need was also significantly higher for women who were married and for women who had discontinued traditional methods compared to those who discontinued the daily pill discussion in line with previously cited literature the firstyear allmethod discontinuation rate reported by the recent senegal dhs was 35 though there was variation by method 46 for daily pills 41 for injectables and 8 for implants 16 the most common reasons for discontinuation were wanting to become pregnant health problems or side effects from using the method and infrequent sexhusband is absent 16 contraceptive discontinuation in the sample of women living in urban senegal was similar to that found for the country as a whole though methodspecific discontinuation of the most commonly used methods was found to be slightly lower in our urban sample the top reasons for contraceptive discontinuation reduced need and method problems were also similar to what was reported in the senegal dhs 16 large differences are known to exist across countries in the rate of method switching after discontinuation an examination of dhs data from 23 countries found that within three months after method discontinuation 64 of women in morocco switched to a modern method while only 17 of women in malawi had done so 17 our analysis found that like malawi method switching was relatively uncommon in urban senegalonly 17 of discontinuations were followed by use of a modern method in the next month discontinuation has previously been shown to account for more than one third of unmet need 6 our assessment of the reasons for discontinuation and contraceptive use status in the month following discontinuation found that about 27 of discontinuations resulted in women who were in need or had an unmet need for contraception the findings of the multivariate analysis indicated that women were most likely to have an unmet need for contraception after discontinuation if they were unmarried had no education or koraniconly education lived in the urban areas of mbour or mbao had at least one child discontinued a modern method other than the pill or obtained contraceptive methods at sources other than pharmacies women with these characteristics are priorities for counseling and provision of information about side effects and method switching at the time of method adoption similar to the welldocumented positive relationship of womens education on use of family planning this analysis found that womens education had a significant association with method switching as well economic status was not found to be significantly related to having unmet need after discontinuation the iud had a high rate of discontinuation due to methodrelated problems specifically menstrual problems and the fear of side effects and health concerns women adopting this method need to receive full counseling on expectations and potential side effects associated with use of the method we found that women who were users of traditional methods were significantly more likely to be switchers to modern methods traditional method use may be a gateway to more effective method use and therefore these women should be supported in this process a recent analysis of data collected at health facilities in senegal found that the general level of counseling for fp was inadequate only 18 of providers counseled their clients on three items examined by the survey 18 yet earlier research in senegal found that women who received good quality care at the time of method initiation were 13 times more likely to be using a method after 16 months than were women who did not receive higher quality counseling 19 such findings indicate that much work needs to be done to improve fp use in senegal this analysis benefited from data collected from a unique sample of women in six urban areas of senegal the data collected from a contraceptive calendar allowed for detailed assessment of contraceptive discontinuation and switching patterns in urban areas beyond what is available in the nationallevel dhs the analysis was limited by recall bias in retrospective calendar data this could include inaccuracies in reporting contraceptive histories as well as reclassification of reasons for discontinuation particularly when it was due to method failure the results presented in the paper may undercount discontinuation due to method failure as the three months prior to the date of the interview were included in the analysis as a result the numbers for pregnancy and pregnancy due to method failure may be underreported the tradeoff was an increase in the amount of data including discontinuations to include in the analysis which is an important consideration as the use of contraception and thus the number of discontinuations were relatively low in senegal furthermore some prior studies accepted a period of three months after discontinuation in which method switching can occur 8 our analysis limits the period for switching to one month following discontinuation due to the importance of maintaining protection against unintended pregnancy maintaining contraceptive coverage and enabling women to switch methods immediately is one of the key service delivery interventions identified in a recent review of literature on contraceptive discontinuation 20 our data would include an additional 56 method switches with an extended threemonth period we did not run separate analyses with these additional switches conclusions while there is no optimal level of method continuation for fp methods it is nonetheless important for programs to monitor and evaluate method discontinuation especially when considered alongside method switching to better understand use trends in a given context or population the results of our analysis suggest that method discontinuation is associated with senegals low cpr additionally immediate method switching to other modern fp methods is low and can be improved this type of information on contraceptive use patterns can benefit fp programming and implementation and bring attention to issues related to discontinuation specifically discontinuation while still in need and method switching issues of programmatic interest include maintaining an optimal method mix at facilities which may include increasing the number of methods available and ensuring there is a mix of methods at all distribution sources programs should provide comprehensive counseling and education on side effects and health concerns dispelling myths and rumors about contraception and how to safely and effectively switch methods when needed assisting women to maintain contraceptive coverage after method discontinuation will help ensure that senegal is meeting the fp needs of its population and contribute to the achievement of its national fp goals abbreviations dhs demographic and health survey fp family planning fp2020 family planning 2020 iud intrauterine device lam lactational amenorrhea method mle measurement learning evaluation authors contributions jbof made substantial contributions to the conception and study design she led the data analysis and interpretation of findings and was lead author for the manuscript is lc and mc made substantial contributions to the data collection study design and interpretation of findings all authors provided critical review of the manuscript and gave final approval of the version to be published not applicable competing interests the authors declare that they have no competing interests

background with the focus of global and national family planning initiatives on reaching additional user targets it is increasingly important for programs to assess contraceptive method discontinuation and switching this analysis calculated the discontinuation rate and methodspecific discontinuation rates examined reasons given for contraceptive discontinuation and assessed characteristics associated with subsequent contraceptive switching and abandonment among women living in urban areas of senegal methods data came from the measurement learning evaluation projects 2015 survey of 6927 women of reproductive age living in six urban sites dakar pikine guédiawaye mbao kaolack and mbour information on contraceptive use and discontinuation for the five years preceding the survey were recorded in a monthly calendar single decrement life tables were used to calculate discontinuation rates descriptive analyses were used to assess reasons for discontinuation and method switching after discontinuation a multinomial logistic regression was used to estimate the likelihood of being a nonuser inneed of contraception a nonuser not inneed of contraception or a method switcher in the month after discontinuation by sociodemographic and other characteristics results the 12month discontinuation rate for all methods was 347 implants had the lowest oneyear discontinuation rates 63 followed by the intrauterine device iud 184 while higher rates were seen for daily pills 38 injectables 327 and condoms 629 the most common reasons for discontinuation were reduced need 456 method problems 301 and becoming pregnant while using 100 only 17 of discontinuations were followed by use of another method most often daily pills 52 or injectables 4 2 in the multivariate analysis women with any formal education primary secondary or higher were more than 50 more likely to switch methods than remain in need of contraception after discontinuation than women with no education or koraniconly education rrr 159 pvalue 0004 rrr 155 pvalue 0031 the likelihood of switching compared to being in need was also significantly higher for women who were married and who discontinued traditional methods conclusions to support increased contraceptive method use women with no education and unmarried women are priorities for counseling and information about side effects and method switching at the time of method adoption

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introduction more than one billion people across the globe have disability people with disability represent 14 20 of the population of developed countries people with disability are twice as likely to be unemployed than people without disability putting them at a higher risk of living in poverty or lacking access to adequate health care the inclusion of people with disability in the labor market provides benefits not only for the person with disability but also for employers and the economy the benefits for individuals with disability include achieving economic sufficiency a strong sense of identity and better quality of life benefits for employers include having access to a diverse talent pool and increasing workplace diversity and productivity economic benefits include increased labor force participation and reduced government welfare expenditure social marketing uses marketing techniques to achieve desirable social change such as greater inclusion of people with disability in society social marketing campaigns which have aimed for greater inclusion of people with disability include the time to change campaign in the uk and the like minds like mine campaign in new zealand evaluations of these campaigns reported that people with disability experience a significant reduction in discrimination the challenge of increasing employment for people with disability can be considered a social marketing challenge because it relies on changing the attitudes and behaviors of individuals to be more inclusive of people with disabilities in the workplace this is increasingly being recognized and new programs are emerging that take a social marketing approach to develop strategies to achieve this examples include dont be my limit and working is a story campaigns to promote the employment of people with disability in spain both campaigns reported a positive shift in employers willingness to hire people with disability employer attitudes have been a major focus of social marketing campaigns which aim to increase labor market participation for people with disability this is because employers unfavorable attitudes are often reported to be a major jsocm 133 barrier to the inclusion of people with disability in the labor market therefore changing attitudes is considered imperative to ultimately changing hiring behaviors the extant literature on the employment of people with disability largely focuses on either the perspective of employers or the perspective of people with disability few studies have considered both perspectives or the potential discrepancy between studies that report employers views which typically report positive employer attitudes and studies that report the perspectives of people with disability which typically report negative employer attitudes in addition limited studies have empirically examined the effectiveness of job placement strategies used by disability employment service providers although they often play a central role in achieving successful employment matches the present study contributes to knowledge of employer willingness to hire people with disability by examining the perspective of disability employment service providers insights can be used to inform the development of evidencebased social marketing approaches that improve employers willingness to hire people with disability literature review the perspective of employers the literature on disability employment reports various barriers to hiring people with disability studies of employers identify attitudinal socioecological and organization structural factors that influence employers willingness to hire people with disability attitudinal factors can be seen in cases of employers who have had meaningful contact with someone with disability such as a positive prior hiring experience and report being more likely to hire someone with disability in future they also report more favorable attitudes toward people with disability especially in terms of their perceived work ethic employer attitudes towards the nature and severity of disability can also influence their willingness to hire a person employers report a greater willingness to hire someone with a physical disability than someone with an intellectual disability because of negative stereotypes such as people with intellectual disability being unpredictable organization structural factors include organizational characteristics such as size and financial resources which can influence employers perceptions of their ability to hire people with disability employers in small organizations report lower willingness to hire people with disability because of the perceived financial costs associated with any workplace modifications that may be required to accommodate them socioecological factors include contextual social norms which influence hiring decisions such as workplace cultural norms and broader community attitudes and expectations regarding the inclusion of people with disability within society for example employers report being influenced by the attitude of their staff toward coworkers with disability because they fear potential disruption to established workplace dynamics most research considers employers as a homogenous group with little attention paid to heterogeneity among employers in terms of differences in their willingness to hire people with disability employers selfreported attitudes toward hiring people with disability are often relatively positive yet empirical studies of employer behavior reveal that employers are less likely to hire someone if they disclose disability in their job application it has therefore been concluded that employers selfreported people with disability acceptance and willingness to hire people with disability may be an artifact of social desirability bias the perspective of people with disability compared to studies of employers people with disability are more likely to report negative employer attitudes as a longstanding barrier to workforce inclusion unfavorable employer attitudes are commonly informed by misconceptions about the ability of people with disability they also stem from a lack of knowledge about disabilityrelated matters including how to best support different types of disability in the workplace as a result people with disability report feeling discouraged from seeking and maintaining employment because they feel undervalued and disrespected the perspective of disability employment service providers the perspective of disability employment service providers features strongly in the area of workplace accommodations and improving employment support services yet there is a lack of research on the actual practices used by disability employment providers to increase employer willingness to hire people with disability approaches to achieving effective matches between employees with disability and employers have been described as a combination of sticks and carrots for example disability employment service providers may approach employers using employment subsidies or discrimination consequences for discrimination theoretical framework the theory of planned behavior postulates that any given behavior is influenced by three key constructs attitude subjective norms and perceived behavioral control attitude refers to beliefs about the outcomes of performing the behavior and the evaluation of these outcomes subjective norms refer to the perceived views of important others in relation to performing the behavior and the individuals motivation to comply with these important others perceived behavioral control refers to the perceived factors that facilitate or hinder the performance of the behavior and the perceived strength of their impact on them personally the theory of planned behavior has been used to gain insight into behavior across a range of different contexts including recycling behavior organ and blood donation the use of bioplastic andvaccination it has also proven useful in the context of investigating the employment of people with disability including by the original theorist using the theory of planned behavior the present study investigates the perspective of disability employment service providers to answer the following research questions rq4 what types of social marketing approaches are perceived to be most effective in increasing employer willingness to hire people with disability rq1 what materials and methodology research context following the international movement for disability rights disability is no longer typically viewed as a medical abnormality rather it is viewed in terms of the social and environmental barriers that hinder the daily lives of people with impairments australia has taken formal steps to support the inclusion of people with disability including the introduction of the national disability insurance scheme this scheme supports people with disability to live an ordinary life by giving them more autonomy and building their skills to participate in society including employment in 2016 a national inquiry sought to understand the barriers to employment for people with disability the inquiry found that employment discrimination against people with disability is ongoing and systemic and that this discrimination is underpinned by negative assumptions and attitudes that are held by many employers and throughout the community as a result australias disability strategy 20212031 considered the increase in employment of people with disability as the first policy priority in australia a federally funded disability employment service program provides support to match people with disability with suitable employment opportunities under this program notforprofit and forprofit organizations provide support services to potential employees with disability disability employment service providers are funded based on their success in matching people with disability with suitable employment as such providers are under competitive pressure to effectively market the employability of individuals with disability to employers and achieve successful job matches a star rating system measures the performance of individual disability employment service providers with each rated from 1 star to 5 stars in addition vocational support for people with disability is also provided by professional groups such as rehabilitation consultants this group has specialist clinical expertise regarding the needs of people with specific disability types in a vocational context sampling and recruitment the population comprised 2200 disability employment service providers in new south wales australia we used stratified random sampling to select a representative sample geographic location and star rating were used as stratification variables creating a sampling framework comprising 25 strata geographical location was classified based on the primary address of the disability employment service provider using the modified monash model the model is a geographical classification people with disability system based on population data that categorizes metropolitan regional rural and remote locations into seven levels according to geographical remoteness and town size disability employment service providers were then randomly selected from each stratum we contacted participants and invited them to nominate a professional in a role that involves matching people with disability to employment opportunities in addition we purposively included a small number of rehabilitation consultants to ensure that the specialist clinical expertise of this group was captured for this group professionals known to the researchers were invited to participate as the participants roles are practically similar we refer to the sample as a whole as disability employment service providers the universitys human research ethics committee provided approval for this research data collection and measures data collection occurred between march and september 2021 the study adopted a qualitative approach using indepth interviews because they involve interpersonal interaction that typically results in a greater expression of participants attitudes and beliefs the interview guide included questions informed by the theory of planned behavior constructs we measured attitudes by asking about the kind of responses participants commonly received when suggesting to employers hiring a person with disability and why employer attitudes were typically positive or negative we measured subjective norms by asking participants about important others that employers consider when hiring someone with disability what those important others typically thought and why we measured perceived behavioral control by asking about the factors that participants perceive to make it easier or harder for employers to hire a person with disability finally we asked participants about the types of approaches they found most effective in increasing employer willingness to hire people with disability data analysis we recorded the interviewees and transcribed the audio files we used a deductive approach by predetermining primarylevel themes using the constructs in the theory of planned behavior and the extant literature on social marketing approaches then we used inductive coding to derive subthemes themes emerged by grouping similar responses on factors participants perceived to be associated with employer willingness to hire people with disability and techniques they used to increase employer willingness to hire throughout the analysis process we adopted a comparative thematic approach to ensure subthemes were repeatedly reviewed and validated results sample description in total 30 individuals participated in the study participants represented organizations from metropolitan regional and rural locations and providers across each of the fivestar ratings table 1 provides detailed sample characteristics description in this section using the framework of the theory of planned behavior we first outline the perceptions of disability employment service providers regarding factors they perceive to be associated with employer willingness to hire people with disability we then identify the social jsocm 133 marketing approaches disability employment service providers have found most effective in increasing employer willingness to hire it should be noted that while rehabilitation consultants perceptions focused more on the employment of people with disability as part of their rehabilitation process the research team did not consider their overall perceptions of employers to be significantly different from those of disability employment service providers for this reason the findings reported in the following sections represent the perceptions of the entire sample of participants although participant job functions are included at the end of each quote to provide context for the particular participant perspective being illuminated figure 1 is a graphical summary of the perceptions captured from disability employment services providers employer attitudes disability employment service providers reported that employers are most concerned with finding the right person for the job it is common for them to hold unfavorable attitudes toward using someone with disability in the first instance the exception is when employers have a prior positive experience with a person with disability in which case they are more likely to hold positive attitudes negative attitudes negative employer attitudes are typically related to stigma and stereotypes or past negative experiences of people with disability stigma involves linking disability as an attribute to undesirable characteristics such as not being able to perform job tasks participants reported having to deal with stigmatizing views of employers the word disability gives people an instant personal reflection on what they while stigma and stereotypes against all people with disability exist they may differ based on the nature of the disability participants perceived that employers are often more favorable toward people with physical disability compared to mental illness or psychological disability one participant explained that employers often express fear when asked to consider hiring a person with mental illness what happens if this person has a meltdown what do you do participants reported that employers perceive that people with mental illnesses will be unpredictable in their behavior and work performance participants believed that stigma is a result of a general lack of knowledge on disability lack of knowledge creates fear and is probably the biggest hinder to employment disability employment service providers try to address this knowledge gap by communicating to employers the benefits and abilities of people with disability rather than what they cant do as long as employers lack knowledge of the benefits of hiring people with disability it is likely that disability stigma and stereotypes will prevail and contribute to sustaining negative attitudes participants reported that employers can develop negative attitudes toward hiring people with disability because of negative past hiring experiences as a result employers refrain from hiring applicants with disability again that one bad experience stands out more than 10 good experiences the supportive role of disability employment service providers is perceived to be a key factor in providing positive hiring experiences for employers what happened was the disability employment service provider opened the door then they didnt know how to support that employer positive attitudes participants reported that employers who expressed more positive attitudes toward hiring someone with disability typically had prior personal experience with people with disability as one participant explained employers feel that theyve been well supported previously and so they want to give back or sometimes the opposite that theyve really struggled that friend or contact and so they wanted to make a difference as a result some employers are proactive in hiring people with disability one employer saw our ad and thought that this was an opportunity where he could help someone because he knew another family friend had a young fellow with an intellectual disability subjective norms participants reported that employers hiring decisions are influenced by groups that participants perceived to be important to employers the groups identified by participants are customers other employees and the wider community customers in customer servicebased industries such as hospitality employers are more likely to be concerned about customer reactions to employees with disability when asked why employers feel this way one participant stated i think because they worry about perception and how business is going to be perceived participants described the negative and positive influences of customer attitudes toward disability on hiring decisions one participant described a job placement that was unsuccessful because of customers negative response to an employers hiring decision one employer said our customers do not want people serving them and putting their groceries in the bags if theyre disabled conversely another participant described a positive experience of customers supporting a local caf e that predominantly hired people with disability as a result other employers in that area became more proactive in hiring people with disability we actually saw a big increase in employers contacting us other employees organizational culture particularly dynamics among employees is perceived as a key priority for employers hiring people with disability can be viewed as a potential threat to workplace culture this can involve other employees being uncomfortable around people with disability employers can be anxious about the other staff and not sure how to treat another person with disability as a staff member it can also cause tension among employees if some employees perceive the productivity of the person with the disability to be lower than theirs sometimes the staff that is there will see that theyre getting paid the same amount as the person with disability and yet theyre having to do more tasks community participants explained that employers generally want to comply with community expectations for example employers in smaller communities are more willing to hire someone with disability because they like the community to view them as being supportive especially where everyone knows everyone else there is probably more of a tendency to be supportive because small communities know a lot of people in their community participants perceive employers based in small communities to be more influenced by community attitudes because of the desire to be perceived as a good community citizen followed by that sense of altruism or social justice or being a good employer perceived behavioral control factors perceived to prevent employers from hiring people with disability include the risk of liability and the cost of workplace modifications and reasonable adjustments people with disability factors perceived to support employers hiring people with disability include disability disclosure and incentives and support schemes barriers participants reported that a key concern for employers is the liability risk associated with a person with disability being injured at work this is particularly the case for people who acquired their disability due to a workplace injury because employers fear that people with workplace acquired disability wont be able to do the job they will potentially injure themselves again and then they could potentially have a workers insurance claim the potential cost of the workplace modifications required to accommodate an employee with disability is also perceived as a barrier for some employers costs may relate to the modification of physical premises or purchasing of customized equipment participants explained that employers commonly expressed concerns such as my place isnt set up for this i dont have the facilities here what things are they going to need any modifications i think its going to cost me money there is a perceived lack of knowledge among employers regarding the schemes available to financially support workplaces that need modifications to make them accessible to people with disability as explained by one participant most employers unless theyve been through the experience dont know those things exist until we talk about them reasonable adjustments are another type of workplace modification whereby job tasks are modified for people with disability so they can perform job tasks for example employers can adjust working hours for someone with disability depending on their work capacity assessment participants noted that employers are often reluctant to implement reasonable adjustments particularly if they involve reducing working hours or allocating time to train and support someone with disability employers want somebody who can be seen as being able to do the role themselves independently and every single part of that role rather than maybe just certain parts of it due to their disability yet participants reported that employers do express a willingness to negotiate reasonable adjustments if they believe that the employee shows a high motivation and willingness to work the employer said well if shes excited im excited facilitators people with disability who are referred to disability employment service providers are not obliged to disclose their disability to a potential employer however participants explained that when this happens it often results in unsuccessful job placement hand on heart i tell you every nondisclosure never works disclosing disability is more likely to lead to a successful job placement because it allows employers to understand an individuals abilities and capacity to perform the role effectively and therefore make an informed hiring decision they know exactly what that person will need how theyll need to be managed and what capacity they can work participants perceived that encouraging potential employees to disclose their disability to employers is critical in alleviating employer concerns and enabling people with disability to give advice to the manager on what they need to do and what kind of support they would appreciate in achieving best outcomes in the workplace participants reported that accessing incentives and support schemes such as wage subsidies can be a strong motivation for employers to hire someone with disability this is because the employer can see that theres a benefit to them investing because it usually does take more time to establish an employment opportunity for someone with disability jsocm 133 in australia wage subsidies are often offered to employers for the first six months of the hiring period and they help to hire people with disability yet they do not necessarily guarantee job sustainability participants reported that some employers are only interested in the financial incentives at end of six months employers give us the excuse that the person wasnt good at their job or the job is no longer available then they approach a different provider and do the same thing this can have a significant negative impact on the employee because they sometimes think that theyve been used social marketing approaches the most common approaches used to increase employer willingness to hire people with disability can be grouped into three types educational interactive and relational educational approaches educational approaches refer to attempts to increase employers knowledge about disability we help them understand more about that disability and more about how employing that person could be of benefit to their business another way of addressing the knowledge gap is communicating messages using social media and televised advertisements which often involve public figures and celebrities people like dylan alcott a wellknown australian paralympian athlete he has been quite outspoken about people with disability getting a job a couple of years ago i would have said it was much harder to approach employers that didnt know about that participants noted the need for messages to address common employer concerns there is not enough information out there for employers regarding the disability schemes i think thats where more information needs to be put out there message design should also account for the different types of disability to prevent reinforcing stereotypes and were critical of those they perceived as lacking in this respect its not giving the whole picture it is just saying everyone thats under disability employment agency must be exactly like that interactive approaches interactive approaches involve direct contact between employers and people with disability for example inperson interviews and workbased opportunities enable the person with disability to gain or demonstrate work skills such approaches are effective because they allow employers to directly observe people with disability in the work environment on a work trial they can get to see the person and get to know them and what theyre capable of and then hopefully offer them a job if things are well this approach also helps applicants with disability to gain skills or relevant skills it can be an opportunity to help improve their work capacity participants noted the effectiveness of the interactive approach with the hiring decisionmaker in the business it can often be the gatekeepers that are the ones preventing the employers from even giving someone a chance this indicates that the successful placement of employees with disability can be influenced by which professional is contacted within the organization people with disability relational approaches relational approaches aim to develop relationships within the community to strengthen relationships with employers this may include for example joining communitybased networks to raise their profile and building rapport with employers highly recognized disability employment service providers in the communities are likely to have greater access to employment opportunities because they understand what the opportunities are because they understand the community use networks to try and identify opportunities relational approaches are used more in nonmetropolitan areas where there is greater reliance on wordofmouth to assess the credibility of disability employment service providers building rapport with employers is critical in establishing professional networks and if they failed to do so its going to be a lot more negative reaction to when we contact them so thats why we really aim for that relational approaches often involve sustained contact between disability employment service providers and employers to advocate for hiring people with disability one example is initiatives that involve employers with positive hiring experiences sharing their stories some of them are really raw and they say i was really nervous i was scared i didnt know what this person what impact they were going to have they share their experiences with others and we believe thats the best way this suggests that strong relationships with credible employers with positive hiring experiences can be highly effective in increasing willingness to hire people with disability discussion and conclusion the current study responds to recent calls for additional social marketing research in the area of disability the key insights gained from this study are threefold first generally speaking disability employment service providers report employer attitudes toward hiring people with disability as negative this supports research which takes the perspective of people with disability and reports stigmatizing attitudes among employers and contradicts findings of research which takes the perspective of employers who selfreport positive attitudes second sources of heterogeneity were identified which are perceived to influence employer willingness to hire people with disability including organizational size and location this is in contrast to much of the extant literature which only considers employers as a homogenous group third disability employment service providers use a range of social marketing approaches to jobmatch people with disability with suitable employers the selection of social marketing approaches changes depending on factors such as employer size and location theoretical implications the present study uses the theory of planned behavior as a framework to examine the perspective of disability employment service providers on employer willingness to hire people with disability examining each theoretical construct separately revealed participant perceptions of attitude subjective norms and perceived behavioral control all perceived to play an important part in employer willingness to hire however the constructs in the framework are considered to have different levels of associations depending on the location and type of organization the employer is from for example disability employment service providers perceive subjective norms tend to have a greater influence on employer willingness to hire in regional and rural areas because the smaller communities are very jsocm 133 positive about employers who are inclusive in supporting community members in contrast providers in larger cities are perceived to have weaker connections with their immediate community and are less concerned about the potential for negative word of mouth that might result from them being less inclusive differences were also perceived in relation to perceived behavioral control with participants observing greater barriers to hiring for employers from smaller organizations such barriers include the cost of workplace modifications and liability risks which could be very costly for smaller organizations with fewer resources at their disposal in contrast participants perceived that larger organizations tend to have greater resources and are driven by more formalized diversity and inclusion policies the existing literature on employer willingness to hire people with disability typically considered employers as one homogeneous group the present study suggests that the influence of attitude subjective norms and perceived behavioral control may differ according to the characteristics of the employers organization and that in this respect we have identified heterogeneity among employers in the factors that may influence their willingness to hire people with disability practical implications disability employment service providers perceive that most employers are not actively seeking to hire people with disability therefore their role is essential to target employers address their concerns and promote the abilities of people with disability using social marketing approaches this could involve downstream social marketing approaches to address the specific barriers faced by an individual employer for example knowing that the perceived cost of workplace modifications is a concern of many employers disability employment service consultants are in an ideal position to educate employers about the range of government financial support available to organizations to assist with the costs of any required modifications they can also provide potential employers with examples of similar local organizations that were concerned about employee performance but that have hired people with disability and experienced outcomes that exceeded their original expectations this could include providing the contact details of managers within these organizations who can attest to their success in this regard failing to do so employment rates of people with disability will remain unacceptably low the skills and training of disability employment service providers in using effective social marketing approaches are key to positively influencing employers hiring decisions this is supported by literature that suggests that transforming social marketing approaches to the disability sector by trained disability employment consultants is likely to increase the inclusion of people with disability in the labor market midstream social marketing approaches could also be used for example by involving communities and business leaders with positive hiring experiences of people with disability to promote hiring people with disability for example creating communitybased initiatives whereby communities are aware of and have avenues to support businesses that demonstrate socially responsible actions such as hiring people with disability this could include listing supportive employers on publicly available websites and providing links to social media sites where members of the community can follow like and share information about the organization within their own social networks these types of approach support literature that highlights the positive effect of communitybased approaches and citizen engagement in social marketing strategies people with disability disability employment service providers are not responsible for advocacy at the policy level and therefore they do not tend to use upstream social marketing approaches while financial support schemes are available to employers disability employment service providers report that employers are often unaware of them or how to access them this suggests that any upstream efforts should encourage the government to increase communications of such support schemes to ensure they reach and motivate employers educational relational and interactive approaches are the key social marketing approaches that disability employment service providers use to promote the potential of people with disability to employers these types of approaches should inform the methods mix which is an important part of any social marketing strategy and a key element of the social marketing benchmark criteria the identified social marketing approaches are often not evidenceinformed but rather guided by the practical experience of each disability employment service provider in considering the most appropriate approach type disability employment service providers should consider the characteristics of the labor market in their location for example providers in smaller nonmetropolitan areas may focus on using relational and interactive approaches targeting employers through community networks these approaches can strengthen employers trust in disability employment service providers and challenge their stereotypes of disability providers in larger metropolitan areas may choose to use educational approaches which dispel myths and concerns employers may have when considering hiring people with disability methodological implications disability employment service providers perceive that employers typically hold unfavorable attitudes toward hiring people with disability in the first instance largely based on a lack of knowledge of disability and negative stereotypes in a limited number of cases employers do have a positive attitude right from the outset but this is usually when employers have prior personal experience with people with disability these findings provide some clarity regarding the conflicting findings of studies that report the views of employers which typically report positive employer attitudes and studies that report the perspectives of people with disability which typically report negative employer attitudes this disparity is likely due to social desirability bias on the part of employers who want to appear inclusive to people with disability this finding suggests that some of the studies which include selfreported attitudes of employers may be questionable in terms of their validity and mask the true extent of discrimination faced by people with disability who want to work the contribution of the present study is providing the perspective of disability employment service providers on employers hiring practices and the challenges that need to be overcome to increase the inclusion of people with disability in workplaces this perspective is widely missed in the literature on employers hiring practices of people with disability therefore the study provides an alternative perspective that can be considered with other perspectives included in the literature limitations and future research the present study was conducted within one specific context of disability employment support in australia despite the geographical limitation findings can potentially be generalized in other countries with similar models of disability employment services and jsocm 133 similar sociocultural and political characteristics such as the ticket to work program in the usa in addition our study used an exploratory qualitative design further quantitative studies with larger samples of employers could quantify the number of employers who hold the different views identified in our study although careful consideration should be given to managing the potential social desirability bias future research should also consider testing different social marketing messages with employers to identify which are most effective in increasing willingness to hire people with disability social security department ticket to work available at sundar v oneill j houtenville aj phillips kg keirns t smith a and katz ee

purpose this study aims to investigate which factors are associated with the willingness of employers to hire people with disability from the perspective of disability employment service providers we also identify social marketing approaches that disability employment service providers consider to be most effective in increasing employer willingness to hire people with disability designmethodologyapproach using the framework of the theory of planned behavior this study examines the association of attitude subjective norms and perceived behavioral control with employer willingness to hire people with disability the authors do this from the perspective of disability employment service providers who are responsible for matching people with disability with suitable employment opportunities the authors used a qualitative approach to data collection and conducted 30 indepth interviews data analysis included deductive and inductive coding to develop the themes and subthemes findings attitude subjective norms and perceived behavioral control were all perceived to influence employers willingness to hire people with disability however the importance of each construct was perceived to differ by location and organization type three key social marketing approaches were perceived to be most effective in increasing employer willingness to hire people with disability educational relational and interactive the educational intervention attempts to increase employers knowledge about disability the

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introduction due to its very nature few health situations will impact the world in this century as the covid19 pandemic has more than 60 million people had been infected worldwide by the end of november 2020 and its impact is apparent in all countries the populations psychosocial health has been significantly affected especially among those who are acutely vulnerable to the virus such as the homeless migrants and refugees the elderly drug users and indigenous populations brazil is currently facing a disheartening situation it ranks third in the number of covid19 cases by the end of november brazil recorded more than 170000 deaths the covid19 pandemic has affected daily life imposing changes beyond the health sphere as social economic cultural and political aspects have experienced impact that is unprecedented in the recent history of epidemics the large number of people who have been infected and died from infection directly impacts the capacity of health systems also challenging countries economies and populations in general continuous and prolonged quarantine causes a strain on peoples mental health as it restricts access to essential goods such as food medicine and transportation among others such a context affects the individuals psychological wellbeing significantly decreasing quality of life these problems are heightened by mandatory social isolation measures intended to control the virus spread the damage caused to human wellbeing is undeniable and has drawn the attention of researchers lawmakers health authorities and public managers who have acted to minimize its impact the pandemics harmful impact heightened by social isolation is quite noticeable in the individuals physical mental social and environmental spheres in this context sexual and gender minorities are subject to greater vulnerability given the historical inequality they face in terms of health and violence a conditioning factor that is these groups are relegated to a marginal position within the society and as a consequence a safety net system and psychosocial support are not always provided or available to them hornet conducted a global survey among men who have sex with men revealing considerable levels of loneliness and depression associated with shelterinplace measures the impact of these measures on the individuals mental health produces considerable impairment in terms of psychological and social wellbeing throughout the pandemic the literature has addressed the pandemics impact on the maintenance of affective and sexual practices including the establishment of barriers impeding access to health services that are necessary to maintain therapeutic processes and care technologies from this perspective there is a lack of concrete governmental action directed to msm during the covid19 pandemic given this populations context and the repercussions of the novel sociohistorical phenomenon caused by the covid19 worldwide on the individuals psychological wellbeing this studys objective was to analyze the factors associated with low psychological wellbeing among msm living in brazil during the covid19 pandemic methods study design this crosssectional study addresses data from the 40tena project conducted in all 26 brazilian states and the federal district from may to april 2020 when restrictive public health measures such as social isolation and shelteringinplace were in force brazilian health agencies instructed the population to shelter at home avoiding closepersonal contact with people outside ones household essential activities such as trade and some services were maintained with restrictions up to the time of this study none of the brazilian states had imposed full lockdown population sample and eligibility criteria a total of 2646 brazilian msm participated in this study due to the pandemic the participants were recruited online using snowball sampling in this method the participants themselves are responsible for recruiting other individuals with similar situations via social media following the methods criteria 15 msm with different characteristics were selected namely the state of residence race age and educational level these were the first participants and were called seeds each participant received a link to the survey and was instructed to invite other msm from their social network until a significant sample was obtained the seeds were identified through two geolocationbased dating applications via direct chat with online users the first individuals available online in each of the two applications and who met the inclusion criteria were included the researchers also promoted the survey on facebook directing it to the msm population aged from 18 to 60 years old using a fixed post on the official page of the survey accompanied by an electronic link that granted access to a free and informed consent form and the surveys questionnaire facebook was used as an additional resource due to its ability to access people located in the countryside which is absolutely necessary in the case of a continentspanning country like brazil only individuals who identified themselves as men and aged 18 years old were included tourists and nonportuguese speaking individuals were excluded data collection instrument the instrument used to collect data was developed by this studys authors considering the research variables and the participants characterization it was content validated by a panel of judges specializing in the topic and method the instrument was divided into four sections with 46 questions most were multiplechoice questions and some were mandatory without answering those questions the participant could not proceed with the questionnaire the questions addressed 1 sociodemographic data 2 psychological wellbeing and coping strategies used during the shelterinplace orders the 5item world health organization wellbeing index validated for the brazilian context was used to assess psychological wellbeing it comprises five items rated on a 5point likert scale with a total score ranging from 0 to 25 who5 was designed to measure psychological wellbeing for the 2 weeks prior to completing the scale scores below 20 indicate the presence of depressive disorder and scores equal to or lower than 13 indicate impaired wellbeing thus psychological wellbeing was classified as low moderate or high sexual practices and activities during the pandemic ie casual sex sex with the consumption of drugs use of condoms protection strategies the strategy used to search for partners frequency of sexual encounters and protective measures against covid19 4 sexual practice and activities before the pandemic were assessed retrospectively adherence to social distance measures was defined as avoiding personal contact with people outside ones household for nonessential activities partial isolation was considered when an individual had direct and recurrent contact with people outside hisher household and total isolation when there was no direct contact the guidelines concerning the presence of signs and symptoms and other clinical variables provided by the brazilian ministry of health were used to define suspect cases of covid19 for security reasons the form used to collect data was hosted by a specific site that enabled only one response per ip data analysis data analysis and statistical software version 120 was used for data analysis descriptive and inferential statistics were used bivariate analysis was performed using the chisquare test estimating prevalence and crude prevalence ratio with a 95 confidence interval multivariate analysis was performed using poissons regression analysis with robust variation the outcome variable was included in the analysis along with each of the associated independent variables with p value ≤ 020 the stepwise procedure was used the sequence in which each term was inserted in the model was determined by a simultaneous analysis of theoretical relevance criteria and statistical significance obtained in the bivariate analysis each term was added or removed from the model after identifying the statistical significance stability of the power of association and akaike information criterion defining the useful subset of terms all variables with a 5 statistical significance remained in the final model to determine the best final model the one with the lowest aic value was selected ethical and legal aspects the research project was approved by the institutional review board at the universidade nova de lisboa and the university of são paulo all the users signed free and informed consent forms before proceeding with the questionnaire results a total of 2646 men who have sex with men participated 1921 of whom were referred by their partners or friends from other social networks a plurality of the men presented moderate psychological wellbeing followed by those with high wellbeing while a prevalence ratio of 79 experienced low wellbeing most were aged from 18 to 29 years old with an average age of 31 years old most were single and fully complying with shelterinplace orders with a duration of social isolation between 30 and 45 days and decreased consumption of alcohol the bivariate analysis of factors associated with psychological wellbeing showed statistical association with age relationship status and social isolation being 18 to 29 years old in a polyamorous relationship and not complying with shelterinplace orders the prevalence of low psychological wellbeing increased by a multiple of 3 2 and 7 respectively social isolation increased the frequency of low psychological wellbeing by 47 other findings are presented in table 2 the variable type of partner was excluded from the multivariate analysis because it presented collinearity with relationship status the association between the presence of covid19 symptoms and testing for covid19 was not statistically significant but remained in the model as a confounding adjustment because the model presented a lower aic the following variables were associated with low psychological wellbeing being in the youngest age group being in a polyamorous relationship not complying with social isolation measures having a higher number of sexual partners having a reduced number of sexual partners and group sex discussion msm living in brazil experienced a lower sense of wellbeing during the shelterinplace orders implemented to restrain the spread of covid19 as more than half of the participants presented some level of impairment in terms of psychological wellbeing the variables that most frequently contributed to this outcome include those related to social isolationdistancing and variables for this reason the context of the current pandemic requires we consider the quality or lack of social interactions and how these situations impact the psychological wellbeing of people as psychological triggers factors such as loneliness change in routine sense of abandonment fear loss of financial stability or unemployment might be intensified this context is likely to cause anxiety decision conflicts decreased selfesteem and interest in life suicidal behavior eating and sleep disorders and alcohol or drug abuse among msm these individuals may become involved in risk practices and expose themselves to the sarscov2 because they are too distressed over the prolonged social distancing measures miss social interaction with people or find restricted mobility to be objectionable additionally opportunities to find affective and sexual partners decreased during the period of social isolation with such efforts largely restricted to online platforms and social networks this may also negatively affect these individuals psychological wellbeing and impact their mental health in this study a greater prevalence of low psychological wellbeing was found among msm who did not report the use of social media to find partners revealing that even though social media is considered to be associated with sex it may play a protective role in times of social distancing by enabling social interactions even if remotely the results from a multicenter study show that 95 of its msm sample was complying with social distancing measures which resulted in a drop in the number of partners and relationships at the same time though there was an increase in online interactions the study also reports that msm devised strategies to keep interactions during the social distancing measures reinforcing this studys findings that interactions whether to seek or exchange content are essential for msms psychological wellbeing the study mentioned above addressed only sexual interactions though so inferences concerning other types of relationships are not possible interestingly having a polyamorous relationship was associated with low psychological wellbeing one hypothesis is that polyamorous relationships do not always occur under the same roof implying that those involved may have to deal with distancing measures that is their contact with each other may be limited for lengths of time additionally polyamorous relationships allow new people outside ones place of shelter and with a possibly different history of exposure to be included in the case of physical contact all those involved are exposed which results in fear and decreased psychological wellbeing consensual nonmonogamy or polyamorous relationships have become an increasingly accepted affective and sexual experience which contrasts with monogamous relationship patterns that are usually considered ideal in stable and committed relationships this context has been intensified among sexual minorities including msm we believe that the fact these individuals are involved in polyamorous relationships and are currently experiencing the impossibility of maintaining the frequency of affective and sexual encounters during the pandemic are coupled with reduced leisure opportunities usually afforded by these relationships decrease these mens psychological wellbeing one cannot rule out the fact that msm in polyamorous relationships usually have to live with stigma this experience may be heightened in a pandemic considering that exclusion and stigma among lgbt populations usually starts at home within the family these individuals may experience rejection and be ejected from their homes causing some even to become homeless in line with this hypothesis this study shows that having a larger number of sexual partners and practicing group sex was associated with low psychological wellbeing which reinforces the hypothesis that having sex with casual partners implies exposure which now includes the risk of acquiring sexually transmissible infections andor covid19 sex is a pleasurable practice to satisfy ones desire and improves an individuals general wellbeing group sex which is usually a source of satisfaction in a pandemic context can lead to psychological distress afterward due to a fear of having being infected by covid19 although these sexual practices in the context of covid19 may incur risks we have to bear in mind that such practices are diverse and vary in terms of the configurations and relationships involved which requires a positive approach considering the specificities of each msm group exposure to often unknown partners or familiar partners who do not effectively adopt preventive measures including those against covid19 increases the fear of being contaminated or anxiety over the possibility of presenting signs and symptoms of the disease leading to low psychological wellbeing increased levels of anxiety stress uncertainty worry and fear may result in having multiple sexual partners and or having group sex considering the constraining role of affective and sexual practices coupled with the advent of a novel infectious disease for which an effective treatment or cure has not been devised thus far additionally the covid19 epidemiological curve in brazil at the time of data collection was ascending with an expressive number of new cases and deaths concomitantly there was an increase in the amount of information provided by the media exposing the complexity of the disease and virulence of sarscov2 which also negatively impacts the individuals psychological wellbeing the prevalence of low psychological wellbeing was approximately six times greater among msm who did not comply or could not comply with the social isolation measures reinforcing the hypothesis that even though the individuals may not comply with social distancing measures to seek interactions exposure still may cause concerns this finding should be interpreted with caution as this study did not assess the context in which people violated social isolation measures socialized with roommates family or coworkers or how people interpreted the questions additionally we should consider that seeking social interactions might not be a matter of choice but rather a compulsive behavior even though it implies a subsequent decrease in psychological wellbeing nonetheless having a small number of partners also negatively affected these individuals psychological wellbeing if on the one hand the individuals want to decrease exposure to protect themselves on the other hand not having the social support provided by relationships and partners which would decrease the pandemics harmful effects could negatively affect these individuals mental health although we know that social support is not only provided by relationships and partners in a context of restricted interactions as experienced in the current pandemic context these individuals assume a prominent role variation in the number of affective and sexual partners may have influenced and decreased the psychological wellbeing of msm and is associated with the low psychosocial support resulting the measures imposed by brazilian agencies to protect people or minimize the impact of the pandemic on mental health longitudinal studies are needed to investigate this finding in more detail in brazil stress has been intensified among minority social groups as their invisibility has been exposed along with a denial of rights cuts in budgets previously designated for the lgbtqia population and naturalized institutional homophobia a lack of directives in public policy mainly affects the youngest segment of the msm population which in this study presented the highest prevalence of low psychological wellbeing almost three times higher than among older msm the world health organization has shown concern with the youngest population segment within the overall context of the covid19 pandemic mainly because these are the most vulnerable from not adhering to social isolation measures an increase in the number of new covid19 cases agglomerations and nonadherence to public health measures to control the spread of sarscov2 has been found in countries already in the summer season the interagency standing committee has proposed specific guidelines to promote mental health and strengthen psychosocial support in emergencies as is the case for the covid19 pandemic these guidelines focus on promoting peoples psychological wellbeing and preventing andor treating mental diseases these goals are achieved by employing multiple approaches that take into account biological sociocultural educational and community characteristics which should focus on reducing harm promoting human rights and equality social participation and valorization of local resources and competencies work via integrated support systems and rehabilitation socioaffective networks are a significant source of access to protection sociability exchange and the maintenance of msms psychological wellbeing and health in the pandemic context and even after the pandemic supporting strengthening and disseminating these networks may be an effective strategy to improve levels of psychological wellbeing decreasing the impact of social isolation such as feelings of loneliness heightened anxiety and stress this studys limitations include its design crosssectional studies do not support conclusions regarding causality that is longitudinal studies would allow better evidence of associations additionally due to the need to comply with social distancing measures populationbased facetoface interviews were not possible except for the msm who did not have access to the internet and could not complete the electronic form finally a probabilistic sampling procedure was not adopted here which impedes the generalization of results to other contexts or countries though the results do provide a situational diagnosis of the msms psychological wellbeing in the pandemic context conclusion the factors associated with the msms low psychological wellbeing were as follows belonging to the youngest age group being in a polyamorous relationship not complying with the social isolation measures not using social media to find partners having multiple sexual partners having reduced the number of partners and group sex the planning and implementation of public policies and actions generally to promote psychological and mental wellbeing intended to increase resilience among msm are needed safe sexual strategies and behavior need to be promoted along with the use of digital technologies to facilitate social relationships by enabling remote interactions these measures can alleviate the harmful effects of the intensified psychological needs accruing from the pandemic context social isolation measures and maladaptive coping strategies data availability the datasets used andor analyzed during this study are available from the corresponding author upon reasonable request conflicts of interest the authors declare that they have no conflicts of interest publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

introduction little is known about how sheltering in place to contain the spread of covid19 over extended periods affects individuals psychological wellbeing this studys objective was to analyze the factors associated with msms men who have sex with men low psychological wellbeing in the covid19 pandemic context method this crosssectional study was conducted online across brazil 26 states and federal district in april and may 2020 the participants were recruited using snowball sampling and facebook posts data were collected using social media and msm dating apps we estimated the prevalence crude prevalence ratio pr and the respective confidence intervals ci95 the prevalence of low psychological wellbeing found in the sample was 79 associated factors were belonging to the youngest group pr 276 ci95 190401 having polyamorous relationships pr 278 ci95 151511 not complying with social isolation measures pr 627 ci95 442887 not using the social media to find partners pr 163 ci95 106253 having multiple sexual partners pr 180 ci95 104311 having reduced the number of partners pr 267 ci95 144495 and group sex pr 182 ci95 123269 conclusion the wellbeing of msm living in brazil was negatively affected during the social distancing measures intended to control the spread of covid19 the variables that contributed the most to this outcome include social isolation relationships established with partners and sexual behavior policy implications planning and implementing public policies and actions to promote psychological wellbeing are needed to improve msms resilience by adopting safe strategies and behaviorpsychological wellbeing • wellbeing • men who have sex with men • gay man • covid19 • sarscov2

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introduction poverty is a worldwide concern in 2013 the world bank estimated that 767 million people were living below the international poverty line of us 190 a day this is equivalent to 107 of the total world population 1 from these numbers 186 million people lived in latin america and the caribbean 2 worldwide rates increase constantly but in some countries this rise is worrying in mexico the poverty rate increased from 455 to 462 between 2012 and 2014 3 older adults are particularly vulnerable to economic insecurity in both lowand highincome countries in 2015 rates of poverty in old age ranged from 32 in denmark to 457 in korea according to the income distribution database of the organization for economic cooperation and development 4 it has been reported that in latin america the poverty rates in older adults are lower than that observed in the younger population however the risk of remaining in this state is higher 56 according to the oecd report 256 of older mexican adults are in poverty 4 while national reports suggest that slightly above 25 of older adults live in this situation 7 recent theories about the influence of accumulated factors throughout life on the presence of diseases in the elderly have increased considerably an example of this is the life course epidemiology framework 8 9 10 that addresses behavioral and psychosocial processes as factors that may exacerbate chronic disease risk during adulthood 11 such as overweight obesity and diabetes 12 13 14 a possible explanation for the association between accumulated factors and chronic diseases is the early establishment of behavioral patterns such as diet and exercise or the appearance of metabolic changes associated with deprivation that may be related to patterns of morbidity in adult life 15 an inverse association can also be proposed as the high costs associated with chronic disease may force adults into food insecurity 16 specifically about diabetes there is limited understanding of the extent to which biological and social risks experienced at different stages of life combine to influence its presence in older adults but plausible explanations have been reported the early establishment of behavioral patterns such as a lowquality diet and a sedentary lifestyle has been reported as possible mechanisms and minority groups are especially vulnerable to adopting unhealthy behaviors 1718 furthermore the appearance of an adaptive metabolic response associated with deprivation 15 and overcompensation during times of relative food adequacy result in fastbinge cycles and have also been linked to insulin resistance 19 in this context this study aims to analyze whether the presence of social disadvantages in childhood and in the present affects the presence of diabetes in older adults materials and methods the present study was based on longitudinal data from the third and fourth mexican health and aging study waves which is a prospective panel study conducted in mexico the aim and design of the mhas are published elsewhere 2021 in brief there are four waves of this study with a representative sample of communitydwelling older mexican adults a set of questionnaires were applied by standardized interviewers who were trained in the objectives of the survey the questionnaires as well as the process of facetoface interview the complete questionnaires can be reviewed at the web page of the mhas at 21 a total of 13628 participants older than 50 years who were assessed in both waves 2012 and 2015 were included after excluding those 50 years those with inconsistent answers to the selfreported diabetes status question and individuals with missing data in the independent variables and the covariables a final sample of 8848 individuals was analyzed the main outcome was diabetes which was considered to be present if the older adult answered yes to the question has a doctor or medical personnel diagnosed you with diabetes according to the diabetes status in both waves three groups were obtained incident prevalent or without diabetes in order to assess factors associated with the incidence and prevalence of diabetes a set of independent variables regarding social disadvantages was analyzed disadvantages in childhood was requested through the questions before you were age 10 did you wear shoes or other footwear regularly and before you were age 10 generally did you go to sleep hungry current disadvantages were analyzed through the question would you say your financial situation is and the right to health insurance inquired by the question do you have the right to medical attention in… also food shortage was evaluated through two questions in the last two years have you always had sufficient money to buy the food that you need those who answered no to the previous question also replied to the following at any time in the last two years did you not eat or eat less than you wanted because there was not enough food in your home covariables were selected based on the criteria of the researchers team variables from different dimensions were explored using the 2012 wave sociodemographic characteristics included age sex marital status and health services provider schooling was also included the dimension of healthrelated variables included selfreported hypertension cancer heart attack lung chronic disease and stroke the mental health related variable was depression measured through a nineitem questionnaire validated in the mexican population the cutoff point positive to depression was a score of 5 or higher 22 internal locus of control was also evaluated through the following questions one is responsible for hisher own successes one can do just about anything heshe puts hisher mind to ones misfortunes are the result of hisher own mistakes and one is responsible for his her own failures 23 and each one with a score from 1 to 4 scores under the average means the presence of internal locus of control and higher scores the absence of internal locus of control data on smoking and alcohol drinking habit were also collected selfreported weight and height were used to calculate body mass index and categorized into underweight normal overweight and obese 2425 health status selfperception was also analyzed in two categories good and bad as described previously by other researchers 2627 an activities of daily living questionnaire was used to evaluate the functionality dimension for the adls 28 participants were asked whether they needed help for walking around the house bathing using the toilet and getting inout of bed the number of limitations present was also analyzed statistical analysis frequencies and percentages were calculated for the full sample and for each group based on the three groups obtained according to the diabetes status in both waves two multiple logistic regressions were fitted 1 a regression consisting of a dependent variable comparing the incident with the no diabetes group and 2 a regression consisting of a dependent variable comparing the prevalent with the no diabetes group variables from different dimensions were selected according with the criteria of the researchers and excluded from the final model because they were not significant all analyses were performed with the statistical package software stata 14® 29 ethical issues the mhas was approved by the institutional review boards and ethics committees of the university of texas medical branch in the usa the instituto nacional de estadística y geograf ía and the instituto nacional de salud pública in mexico the current analysis was registered at the instituto nacional de geriatría results a total of 8848 participants were included in the analysis the flow of participants can be seen in fig 1 from the sample studied 459 participants were classified in 2015 as incident cases and 1903 as prevalent cases a total of 6486 participants were free of disease in 2012 and 2015 sociodemographic characteristics of the studied population are reported in table 1 mean age is similar between groups 6368 years old except for the ig which reports a slightly lower mean most of the participants were women and percentages range from 5446 in the ndg to 6201 in the pg regarding schooling no differences were found either in the number of years of formal education or in the percentage of participants without education the percentage of individuals reporting bad selfperception of economic status was higher in the pg followed by the ig regarding health services provider most of the participants were insured by social security institutions and percentages range from 5182 in the ndg to 5577 in the ig from the total sample 1088 reports not having a health service provider fig 1 flow of participants clinical and psychological characteristics of the studied sample are presented in table 2 selfreport of diagnosed hypertension heart attack and stroke were higher in the pg followed by the ig depression prevalence was found higher in the ndg percentages of participants with internal locus of control and history of never drinking alcohol were very similar among groups the proportion of participants who reported never smoking was higher in the ig and pg compared with the ndg as expected percentages of overweight and obese participants were higher in the ig as well as in the pg report of bad selfperception of health was more frequent in the pg and the ig compared to the ndg with regard to functionality percentages of disability were very low the higher percentages were found in the pg for all types of adl also the percentage of individuals with one or more limitations was higher in the pg compared with the ig and the ndg concerning the social determinants a higher percentage of individuals that reports no shoes during childhood was found in the ig smaller percentages were reported in the pg and the ndg went to bed hungry not having enough money to buy food during the last 2 years and household food shortage percentages were similar between groups the odds ratios associated with a logistic regression that compare the incident with the no diabetes group are presented in table 4 first column the full logistic regression model containing all six main predictors and all the covariates was statistically significant only the predictor variable no shoes during childhood was finally the odds ratios associated with a logistic regression that allows us to compare the prevalent with the no diabetes group are presented in table 4 second column it can be observed that the full logistic regression model containing all six main predictors and all the covariates was statistically significant only health services provider was statistically significant thus first when holding all the other predictors constant a person covered by more than one health service is 121 times more likely to be a prevalent instead of a no diabetes case than a person affiliated to social security institutions second a person without medical services is 061 times more likely to be a prevalent instead of a no diabetes case than a person affiliated to social security institutions the odds ratio for age indicates that patients between 60 to 69 years old are 127 times more likely to be a prevalent instead of a no diabetes case than those between 50 and 60 years old on the other hand people aged 80 years or more are 049 times more likely to be a prevalent instead of a no diabetes case than people in the reference group for bmi a person with normal weight is about 133 times more likely to be a prevalent instead of a no diabetes case than a person with low weight controlling for the other predictors in the model the results are similar for overweight and obese people current smokers are 075 times more likely to be a prevalent instead of a no diabetes case than those who had never smoked a person that drinks in a moderate or severe way is 075 and 073 respectively more likely to be a prevalent instead of a no diabetes case than a person who did not drink alcohol people with bad health selfperception are 267 times more likely to be a prevalent instead of a no diabetes case than those persons with good health condition controlling for the other predictors history of hypertension or heart attack tend to be prevalent instead of no diabetes cases but participants without lung chronic disease have lower odds of being prevalent case compared to ndg in 29 also getting help walking around the house or eating makes people more prone to diabetes discussion this study presents the results of the relationship between social disadvantages during childhood and at the present and the incidence and prevalence of diabetes in a national representative sample of older adults due to the longitudinal design of the mhas we were able to examine how social disadvantages during childhood and adulthood influence the likelihood of diabetes outcome consequently it appears possible to elucidate whether either adulthood factors or early life socioeconomic conditions are the most critical outcomes associated with having diabetes the findings from this study are partially congruent with other studies 30 31 32 33 the only social determinant that was significant to the incident cases versus ndg was no shoes during childhood the other indicator of childhood poverty went to bed hungry before 10 was not found associated from the descriptive analysis we found similar proportions of these two variables between the groups no shoes during childhood is a widely used indicator of child poverty 3435 specifically it has been reported as part of the basket of nonfood items 36 and used by various international organizations as an indicator of effective satisfaction of needs reflecting not only economic but social deprivation 37 on the other hand it has been reported that child poverty is strongly related to the presence of diabetes later in life 3839 then it may be possible that the indicator no shoes during childhood could be a stronger indicator of social disadvantages poverty and a predictor to diabetes incidence against expectation only this indicator was significant a reason behind could be that no shoes during childhood is a more objective indicator not affected by the possible memory bias of participants we further found that social constraints at early stages in life can lead to a chronic lack of resources and are linked with the presence of chronic disease such as overweight obesity and diabetes during adulthood 12 13 14 it is well known that the choices made by children and adolescents are strongly affected by the family and community environments in which they live but also impoverished living conditions prevent people from engaging in healthy behaviors 40 how is poverty linked to obesity and diabetes 41 it has been suggested that poor families choose high fat sugar and sodium foods because these foods are more affordable convenient and last longer than fresh vegetables fruits and lean meats and fish 42 lowincome families often live in disadvantaged neighborhoods where healthy foods are hard to find 43 44 45 46 but also economic problems such as troubles paying the rent or bills stress people and they often cope by eating highfat or sugary foods 47 on the other hand individuals who live in impoverished regions have reduced access to parks or gyms for regular physical activity in many poor neighborhoods parks free public gyms are often not available or safe 48 49 50 51 a result that consistently was present along the three groups was the body mass index an increased and statistically significant odds ratio was present not only for overweight and obese participants but also normal weight group versus low weight individual this finding represents not only a clear and strong relationship between weight and diabetes 52 but also it could mean that the cutoff point could be biased towards the underestimation of risk it is important to highlight that the reference values used for the bmi in the present analysis were those proposed by lipschitz 2553 these cutoff points consider that in older adults weight tends to decrease due to a reduction in body water and muscle mass if the traditional bmi classification for adults 54 would have been used the individual risk for diabetes would be lower for those classified as normal weight and higher for those in the overweight and obesity groups nevertheless the direction of the association shows that the risk of developing diabetes increases with a higher bmi the evidence is more robust for the longterm influence of early life vulnerable socioeconomic conditions on the development of diabetes 1332 during adulthood in our study current disadvantages do not appear to contribute more to the association than social disparities during childhood however other variables such as age health services bmi and health perception overshadowed the association between early life socioeconomic conditions and diabetes the presence of adverse socioeconomic conditions in the early stages of life have a significant potential impact on health at older ages 55 when the incident group was compared to the no diabetes group having hypertension seems to be associated with the occurrence of diabetes this association was expected as concomitant diabetes and hypertension is a frequent condition in older adults 5657 in our sample of prevalent cases against no diabetes cases we found that having more than one health service increases the risk of being a prevalent case why might the pathway via insurance coverage be so critical before considering possible explanations we need to consider whether this finding could be because of selfreport response bias since the analysis is based on selfreported data the data from the mexican health and aging study may underestimate the prevalence of diabetes thus the association between affiliation to social security institutions and prevalence of diabetes needs further study when we compare pg versus ndg the figure indicates that it is a protective factor and it can be seen as an indicator of diagnosis delay 58 in this regard it is worth noting that not having received the diagnosis does not mean the absence of disease also some differences between ig and pg could be explained by clinical course and time living with the disease a process of adaptation to the disease and survival could also be a reason of differences between pg and ig this study has several limitations the measurement of childhood conditions can be subject to recall bias in this respect previous reports support the ability of people in recalling earlylife events and childhood health conditions 59 so that information can be considered a good approach to the earlylife information in this sample of older adults also considering that objective measurements along the life course are difficult retrospective reports are a reliable source of information for the selfreported diabetes condition this recall bias might have affected our findings regarding the real presence of the diabetes diagnosis and its predictors in this sense it has been reported that prevalent selfreported diabetes and incident selfreported diabetes has 8497 specificity and 5580 sensitivity in respect to multiple reference definitions also the reliability of selfreported diabetes is 92 at all time points 60 in this sense our results can be considered an accurate approximation to the presence of diabetes in older mexican adults taking into account that the no shoes during childhood variable is not an indicator of childhood poverty commonly used in other research comparisons with other populations may be difficult notwithstanding this indicator confers a novelty to our analysis as it has demonstrated to be a reliable indicator of childhood poverty and a good predictor of diabetes a highly prevalent chronic disease in older adults however we suggest that a single indicator need to be used with caution as poverty is a more complex phenomenon competing interests the authors declare that they have no competing interests

background social disadvantages that start during childhood and continue into the later stages in life may be linked to the presence of diabetes during adulthood objective to analyze whether the presence of social disadvantages in childhood and in the present affects the presence of diabetes in older adults methods the present study was based on longitudinal data from the third and fourth mexican health and aging study mhas waves 2012 and 2015 data on diabetes diagnosis past eg no shoes during childhood and present eg selfperception of economic status social disparities and other covariables were analyzed results from 8848 older adults 215 n 1903 were classified as prevalent cases pg 52 n 459 as incident cases ig and 774 n 6486 were free of disease ndg the predictor variable no shoes during childhood was statistically significant in the model incident versus no diabetes group hypertension and body mass index bmi were the most relevant covariates as they were statistically significant in the three groups pg ig and ndg conclusions not having shoes during childhood an indicator of social disadvantages is associated with the incidence and prevalence of diabetes in older adults this suggests that social disadvantages can be a determinant for the presence of chronic diseases in adulthood

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economic health of us cities varies both between and within them when city leaders manage economic development they typically have at their disposal established research to guide their efforts largely absent from that literature are strategies for boosting inclusion of marginalized groups as a part of urban renewal this is needed because as cities expand their economies wealth inequalities within them tend to expand too when benefits from economic growth are unequally distributed across residents excluded people of color bear the social consequences social exclusion … involves the lack or denial of resources rights goods and services and the inability to participate in the normal relationships and activities available to the majority of people in society whether in economic social cultural or political arenas it affects both the quality of life of excluded individuals and the equity and cohesion of society as a whole exclusion from opportunities has been stratified by race in us cities drawing from multiple theory lenses we propose a model in which leader gender is associated with economic health of cities and this relationship is mediated by ethics of care leadership focused on racial inclusion studies have mostly surveyed if economic growth leads to inclusion and the results are mixed some cities have strong economies but low inclusion while others show high inclusion and poor economic health and yet in other cities there is no connection in the present research we examine if racial inclusion is related to economic health in this way more residents contribute to the local economy but city leadership is needed to promote inclusion in the first place because our research context is the revitalization of urban environments the leaders we examine are mayors leadership a process of motivating effective group behavior is vital in amorphous social contexts in which practices from predictable times are unlikely to apply leadership research has offered few answers to the urban crisis and the role mayors might play in it literature on a female leadership advantage suggests that women in comparison to men might be more effective leaders when organizations are in crisis drawing from this literature we examine if and how womenled cities might be more effective than menled cities in terms of economic health we propose that this relationship is mediated by ethics of care leadership manifested by greater racial inclusion in line with our focus on cities we take a sociological perspective on racial inclusion and consider it at the group level thus inclusion represents unimpeded access to economic opportunities and other benefits for city residents regardless of their race or ethnicity because a key exclusion fault line in the us falls along race and ethnicity we examine inclusion of people of color represented as anyone who selfidentified in the us census as nonhispanic white ie black or african american asian american indian and alaska native native hawaiian and other pacific islander other race two or more races or hispanic or latino ethics of care was developed in response to traditional moral theories ignoring feminist critiques of them caring is critical to survival as infants and children fully depend on others to care for them to say nothing of caring being instrumental for people to live in social harmony that is caring can be viewed as an activity that includes everything that we do to maintain continue and repair our world so that we can live in it as well as possible women tend to engage in caring more so than men and it has been established that women consider care a moral virtue yet for example pincoffs lists 221 personal virtues but care is missing similarly macintyre recognizes the importance of human dependency on one another yet fails to acknowledge care as a moral virtue feminist philosophers argued for the consideration of care as an ontological virtue and pushed for its inclusion in the epistemology of moral theories known as ethics of care today ethics of care framework enables women to better discern their voices and contributions in creating a caring society across domains of activity bridging this theory and leadership research we introduce ethics of care leadership a framework in which ethics means that care is wanted and unobtrusive care is the value and leadership is the practice of attentiveness toward others responsiveness to their needs and cultivating caring relationships we propose that women mayors compared to men are more likely to achieve economic health by fostering racial inclusion in their cities because they are more likely to embrace ethics of care leadership we pooled data from multiple public sources into a unique dataset that includes 1185 cityyear observations spanning 272 us cities and 971 unique mayors over 36 years with five measurement points results from complementary analyses supported our hypotheses compared to cities with male mayors those with female mayors were associated with healthier economies and this finding was mediated by greater racial inclusion this study makes the following contributions first scholars have made calls for greater involvement of leadership research in addressing social issues we answer this call by bridging fla research and ethics of care moral philosophy and by studying it within the general context of the urban revitalization crisis in the us in this context a crisis is defined as a cooccurrence of highimpact issues that can create ripple effects if left unaddressed fla studies on leadership in crises have mostly focused on organizational crises where prompt action is needed mayor gender racial inclusion economic health h1 h2 h3 fig 1 conceptual model of a female leadership advantage as a pathway to an ethical city though valuable findings from those crisis contexts might not translate to effective leadership qualities during an ongoing societal crisis unlike organizational crises the constellation of factors contributing to a chronic societal crisis form over time to create enduring tensions for which an immediate fix is not readily discernible exclusion by race in us cities over decades has led to segregated experiences across the nation giving rise to an urban crisis characterized by racial gaps in spatial segregation homeownership poverty and education we leverage this ongoing social crisis to answer a call made by post and colleagues for more research on gender and leadership effectiveness in various crises contexts second one problem in the fla literature is that studies on gender and leadership effectiveness tend to lack explanatory mechanisms linking gender and outcomes as reviewed by hoobler et al leaving pathways unspecified that may elucidate ways in which women leaders achieve outcomes has led critics to label fla research a body count or subjective tokenism by conceptualizing and testing a mediation model in which a fla unfolds through ecl focused on racial inclusion we contribute to a still relatively open question of what broad gender differences might inform womens leadership effectiveness third the design of this research has reasonable ecological validity because it is based on reallife data from the urban crisis in the us as it unfolded over nearly four decades multiple and objective measures of the criteria add to construct validity and robustness of the findings literature review and theory development a female leadership advantage gender differences in leadership styles and their effectiveness were first realized following two groundbreaking studies in 1990 both foresaw an opportune juxtaposition of two trends dubbed a fortunate confluence helgeson business upheaval of the 1980s and the growing influx of women into management roles the former called for exploration of new leadership styles because the standard practices from more predictable times were unlikely to apply and the latter movement provided fruitful answers as explained by helgesen as historic outsiders to such positions women often had fresh eyes to see what was no longer working and to identify new solutions similarly rosener predicted that by valuing a diversity of leadership styles organizations will find the strength and flexibility to survive in a highly competitive increasingly diverse economic environment instead of enumerating alleged handicaps of women in business as was common practice these studies focused on what women could offer in the changing workplace compared to an earlier study by mintzberg in which five male executives reported being essentially company men helgesen and rosener found that women approached work differently mintzberg had documented that men tended to work long hours rely on a topdown chain of command monopolize information at the top have a deep but narrow focus develop skills to follow procedures value conformity to corporate norms and focus on goals competing and wining in contrast helgesen and rosener found that women tended to share information invite participation in decisions making engage in relationship building ensure others felt included and take a longterm focus female leaders did not perceive themselves as company women following typecast norms instead they saw themselves and their colleagues as humans with varied backgrounds who react differently to work challenges in both studies women achieved business results fulfilling the role of agents of transformation helgeson coined the phrase female leadership advantage to describe her findings and rosener summarized her findings on gendered leadership characteristics as tending to be transactional for men and transformational for women although methods in these early studies were criticized the idea of genderdriven leadership effectiveness gave rise to many studies in the following decade generally this research found similar results ie men tended to espouse power make topdown decisions guard information have a transactional view of employees exhibit competitiveness assertiveness and a willingness to take risks whereas women leaders seemed to embrace inclusiveness information sharing caring kindness and compromise eagly and colleagues metaanalyzed much of this research and results largely affirmed a fla while these findings do not imply that all women espouse caring values and men do not they do indicate the existence of genderbased differences that can shed light on womens leadership approaches critics argued that evidence behind a fla is insufficient to be convincing and debate ensued social role theory suggested that a fla can turn into a disadvantage when sex roles are stereotyped and enacted against the social stereotype glasscliff research on the other hand suggested that women more so than men are appointed to leadership during times of uncertainty simply because there is less competition for precarious positions together being a woman leader has been viewed as an advantage a disadvantage or neutral we suggest that a fla can be at least partly ascribed to gender differences in moral values in mainstream moral psychology values such as independence selfdetermination and individual rights are prioritized and there appears to be a systematic devaluing of notions of interdependence relatedness and positive involvement in the lives of others though the former values are important walker argues that they represent the moral agent showing how the rest of us ought to act these values espoused by dominant figures in a social order largely elude the daily experiences of women such as caring for family building and maintaining relationships and addressing needs of those who rely on community members for aid evidence from multiple sources including psychoanalytic practice has converged in support of care as a moral value and studies suggest care tends to be more valued by women than by men 1 put simply applied psychology research has virtually never found that women exhibit more interest on average than men in pursuing economic gain at the expense of community nor that men are more inclined on average than women to focus on care at the expense of business interests these gender differences in the value placed on care as a moral virtue seem likely to lead to differences in the degree to which ethics of care leadership is espoused alternatively strengthening stereotypes associating women as communal may prompt women to intentionally conform to norms and avoid backlash by leading in more caring ways further selectionbased views of leadership might suggest that women who support express or embrace ethics of care will be more likely to be promoted to leadership roles because this style conforms to social role stereotypes whether differences in ethics of care leadership arise from gender differences in moral virtues as we suggest or from a blend of reasons suggested above we suggest that women leaders are more likely to embrace ethics of care leadership ethics of care leadership and racial inclusion ethics of care leadership is an activity that involves expenditure of physical and mental energy it is not a mere attitude such as i do not care for this or that nor is it just a warm feeling for someone ecl is a behavior aimed toward the wellbeing of a relationship and those in the relationship to clarify this does not include caring for all of humanity all the time instead it is caring for those in a particular personal or social relationship which can comprise of any number of people including an entire community for this reason the interests of those caring and those who are caredfor are interwoven rather than independent or competing and caring is voluntary rather than contractual this literature rejects the view that caring is simply a biological necessity as a means of survival and hence not a moral virtue in contrast acts of caring can be transformative as they help people gain capacity to live in mutually beneficial relations with others for example when in crisis people can feel overwhelmed and uncertain of how to move forward caring leadership is what many in the community look toward for a viable path out as well as seeking help with the discomfort racial inclusion is aimed at building a more equitable society and those efforts can benefit from ecl generally there are three aspects of inclusion first inclusion is more than an outcome to strive for it is a process of connecting people and opportunities especially excluded communities second relatedly inclusion scholars and practitioners have argued for a holistic approach to studying it versus focusing on single issues in isolation finally to bring inclusion to fruition there needs to be a purposeful vehicle of initiative through which a process of social inclusion can be operationalized ecl with its emphasis on caring might be that vehicle of change toward greater inclusion in urban areas ethics of care has been advocated for in the political arena which transitioned into an emerging literature on ethical cities in an ethical city leadership strives toward inclusive community life both economically and socially this goal is in relative contrast to prior conceptions of city leadership for instance in a neoliberal city a citizen is seen as the consumer and city governance is modeled after a forprofit enterprise hence typical mayoral priorities focus on economic development maintenance and development of infrastructure offering reliable public services and if possible boosting consumer spending these traditional mayoral activities have helped cities amass substantial resources however those resources are often found in segregated allotments signaling exclusion of people of color from opportunities business growth is critical as a tide that raises all boats but markets can be exclusionary of some communities in this uplifting process we highlight a new perspective on mayoral priorities associated with ecl that differ from positions focusing exclusively on revitalizing cities via an influx of business development we propose that mayors who embody ecl go beyond revenuegenerating and budgeting by also recognizing and accommodating the diverse interests and groups embedded in urban life under ecl governance is mutually reinforcing as mayors make intentional choices to rebuild communities and make their cities more inclusive deliberate effort toward inclusion is needed because sole reliance on markets to fix the problem has been ineffective urban inequality remains an endemic and worsening experience for many indeed … inequality is the key challenge facing our cities we extrapolate research that finds that women value care as a moral virtue more so than men to suggest that women leaders are more likely to embrace ecl as a result compared to men women mayors are more likely to foster greater racial inclusion in their cities through the following set of practices first they are more likely than men to generate greater and more fruitful engagement with those they lead ecl follows rules as an important baseline but cultivating relationships moves the community forward together on average women tend to be more engaged than men in their communities centering their involvement around volunteerism and activism for instance research indicates that women leaders actively oppose toxic waste storage near residential areas work with vulnerable city youth and advocate for affordable housing for urban revival to be effective buyin from fragmented community members is crucial because inclusion cannot be forced it is unclear how mens tendency to use hierarchy and power to compel compliance would stimulate inclusion across racial lines relatedly in approaching dilemmas men tend to be more concerned with justiceinterference with others rights in impermissible waysthan with care thus men tend to make decisions using rules regulations and traditional ways of doing business this is important for maintaining order but it does little to nurture racial inclusion research in political science public policy and gender studies corroborates these links for instance men and women legislators report approaching their roles differently men tend to approach equity issues with an agendaimprovement mindset by supporting incremental changes to existing programs fixing issues within extant bureaucratic procedures and allocating funds to regulatory bodies in contrast women politicians are more inclined toward agendabuilding such as reshaping the agenda transforming the agenda offering new views and ways of doing things and prioritizing novel inclusive policies these differences have been documented in state legislatures congress and in comparisons of men and women city managers another factor through which women mayors might foster greater inclusion is by being more attentive to human differences compared to men women leaders tend to be more sensitive attuned and responsive to moments of differences and feel responsible for working with the differences this suggests that women leaders are more likely than men to consider multiple stakeholder perspectives learn from multiple constituencies and coursecorrect toward inclusion and community building this type of broad collaboration enables women leaders to leverage knowledge and skills from multiple stakeholders and make decisions by drawing from a richer source of information in this way women are often seen as relational leaders who value interdependence benevolence and tolerance together women leaders form a we are in this together platform underlined by a because we care value by nurturing collaboration across city constituencies women leaders galvanize effort toward racial inclusion organizational leadership research on ceos and board members likewise supports these connections for example corporate women leaders compared to men are more likely to prioritize broad initiatives related to inclusion equity and social responsibility and organizations with female top executives have fewer discrimination lawsuits similarly studies on politics policy and gender suggest that women legislators in comparison to men devote more effort to wideranging social programs that provide aid to underprivileged communities and cosponsor policies that seek to more evenly spread wealth racial inclusion in cities manifests in racial spatial segregation as well as racial gaps across homeownership poverty and education to illustrate how mayors can improve inclusion we identified several reallife examples of policy making levitt et al outlined reporting standards that called for quotes or excerpts to augment data and to demonstrate that findings are grounded in evidence in addressing inclusion not all mayors pursue the same action and some choose inaction for example of the 1621 mayors and officials who perform mayoral functions of us cities towns and civil divisions with populations over 30000 in 2021 only 143 signed the mayors contract on racial equity publicly committing to promoting racial equity compassion and justice for all city residents2 although women constituted only 25 of us mayors in 2021 they represented 40 of the mayors who signed this document this suggests that women mayors in comparison to men appear more likely to prioritize racial inclusion in their cities miami mayor francis suarez refused to sign the inclusion pact pointing to differences in approaches to inclusion he stated we would love for everyone to be prosperous … but were trying to find the right balance … fostering innovation to empower people to be able to do that on their own in contrast to mayor suarezs approach mayor libby schaaf of oakland ca announced a privately funded project that afforded lowincome families a chance to secure steady income for 18 monthsno strings attached when explaining her policy choice she stated we believe that poverty is not personal failure it is policy failure mayor of chicago lori lightfoot introduced a fiveyear plan to tackle racial spatial segregation by increasing education and outreach for voucher holders to encourage minority families to live in higher opportunity areas she further introduced incentives and rezoning initiatives to boost affordable housing by encouraging multifamily unit developments near transit hubs mayor muriel bowser of district of columbia similarly sought to promote inclusion in her city by creating a task force to identify actionable steps toward greater minority homeownership she explained that goal was to …address decades of racially discriminatory policies and practices that have hampered access to one of the most significant ways to build wealth for black residents … i intend to chart a path to rectify these problems … and to set a 2030 goal for black homeownership 3taking another approach mayor amy shuler goodwin of charleston wv partnered with a charity to secure funds for a city plan aimed at improving lives of those residing and working on the west side of charleston by increasing access to housing and jobs mayor regina romero of tucson az allocated federal funds for youth employment and lowincome housing explaining what were trying to do with american rescue dollars is bring about transformative change through investments in the causes of poverty st louis mayor tishaura jones allocated those same funds for cash payments to residents of color explaining its a priority for me to address the historic disinvestment of black and brown communities…when we provide support to those who need it most we will stabilize our communities taken together we offer the following three hypotheses h1 cities led by female mayors are likely to be associated with better economic health compared to those led by male mayors h2 cities led by female mayors are likely to be associated with greater racial inclusion compared to those led by male mayors h3 racial inclusion of the city mediates the relationship between mayor gender and economic health of the city method data sources we used the inclusive recovery report publicly available data released by the urban institute 4the urban institute collected data on us cities with a population of 100000 dating back to 1980 only incorporated cities with a municipal government were included in their dataset because these cities have leaders with authority over economic and social policies measures of inclusion and economic health were available for 274 cities at five points in time this resulted in a dataset of 1370 cityyear observations of these we identified the mayor for 1185 observations of the missing observations 173 related to 1980 1990 or 2000 as online archival capabilities were lacking compared with 2013 and 2016 5 we analyzed the entire dataset on both criteria using marginplot from vim 611tgz package in r and confirmed that missing data were randomly distributed hence the coefficients and standard errors are unlikely to be biased measures mayor gender research assistants blind to hypotheses coded the mayors gender a predictor in our model as female or male from biographies and pictures available online of the 971 mayors in the dataset 172 were women racial inclusion a mediator in our model this construct represents the ability of residents of color to contribute to community life and share in its benefits the urban institute defines residents of color as those who do not identify as nonhispanic whites according to their selfidentification in the us census 6for each indicator variable included in the racial inclusion construct raw scores were collected and converted by urban institute to zscores reflecting the relative score of each city on the indicator variable in comparison to the full 274 city sample with 0 as the mean and 1 as the standard deviation racial inclusion indicator variables were chosen by the urban institute to reflect policy areas over which city leaders have some control so that the indices can directly inform local policy change and each indicator was weighted equally by urban institute thus the racial inclusion measure is a comparative index or average zscore across four indicator variables and it represents the relative racial inclusion score compared to other cities included in the sample 7 the zscore was computed fig 2 missing data diagnostics measures of inclusion and economic health were available from the urban institute for 274 cities at five points in time this resulted in 1370 cityyear observations of these we were able to identify the mayor for 1185 observations we analyzed entire dataset on both dependent measures using margplot from the vim 611tgz package in r in the left panel the green data points represent observations of racial inclusion index separated by whether the mayor was identifiable in the right panel the blue data points represent observations of economic health index separated by whether the mayor was identifiable the data across both dvs in the right column appear to be randomly distributed confirming the data are missing completely at random by urban institute such that a high score represents greater racial inclusion spatial segregation the first indicator variable of racial inclusion is spatial segregation by race measured by a dissimilarity index 8 this index reflects the relative distributions of two groups across neighborhoods in the same city it ranges between 0 and 100 indicating the percentage of one group needing to move across neighborhoods to be distributed equally to the second group where 0 indicates both groups are distributed proportionally across all neighborhoods as this index was used in prior research residential segregation represents spatial circumstances that curtail opportunities for participation in civil society for those living in them it is a limiting context because a persons patterns and norms of behavior tend to be shaped by those with which he or she has the most frequent or sustained contact and interaction the result can be a clustering of neighborhood attitudes and practices that deepen exclusion of local residents from the rest of the community whether reasons for spatial exclusion are misguided housing policies market forces in the form of prejudicial realestate practices and or personal biases residential segregation comes with a shortage of opportunity has high barriers to exit and it persists compounding inequalities mayors can take steps to mitigate residential segregation with a mix of policy initiatives such as foster housing density near mass transit employment and services sharing information about voucher programs for education if they exist and encouraging mixedincome communities homeownership gap the second indicator variable of racial inclusion is a racial homeownership gap 9 calculated by subtracting the percentage of homeowning households of people of color from the percentage of homeowning white households homeownership has been a significant source of wealth accumulation in the us but many people of color have not been privy to it historically legal barriers to home ownership were removed by the 1862 homestead act guaranteed by the 14th amendment to the us constitution and fair housing rights were pledged in the fair housing act of 1964 however discrimination in homeownership continued in the marketplace through white flight realestate agents steering races away from each other and bank redlining and refusing mortgages to minorities while promoting home ownership among the whites these discriminatory practices were commonplace even in some of the most liberal areas eg … the fha agreement specified that no properties be sold to african americans the builder then constructed individual homes for sale to whites in ladera a subdivision that still adjoins the stanford campus many of these practices were justified on economic grounds eg california real estate association warning that negro invasion was imminent and that it would result in collapse in property values to avoid explicit racial intent the discriminatory impact of these practices on homeownership of people of color persists today mayors have authority to enact several remedies for example they can apply for and allocate federal and other funds to help reduce inequality in home homeownership as well as establish task forces to address social and racial housing inequities and foster initiatives that put city housing goals at the forefront of community planning poverty gap the third indicator variable of racial inclusion is a racial poverty gap 7 this is calculated by subtracting the poverty rate for the whites from the poverty rate of people of color though racial inequality in poverty declined in the last 30 years racial income disparities remain the urban institute included this as a measure of racial inclusion because occupational 8 urban institute used data from brown universitys american community project for 1980 1990 and 2000 for 2013and 2016 urban institute calculated these figures using census bureau acs estimates 9 urban institute obtained these data from the national equity atlas footnote 7 index our approach differs we use inferential statistics not rankings allowing us to treat diversity as a covariate in our models diversity alone in our view does not automatically imply inclusivity as greater diversity could also correspond to greater segregation segregation persists with racial minorities tending to be concentrated in jobs with lower levels of stability and with fewer advancement opportunities thus a lower poverty gap would suggest that leaders have made policy efforts to curb occupational segregation although most mayors agree that a racial poverty gap is a problem they differ on solutions for instance mayors can enact programs targeted at increasing small businesses owned by minorities and can create programs that improve their access to capital some mayors have even adopted a universal basic income program to provide minimum monthly payments to lowincome residents or adopted programs that offer financial assistance to minority residents education gap the fourth indicator variable of racial inclusion is an education attainment gap 10 this measure is derived by subtracting the percentage of the white population with a high school degree from the percentage of person of color population with a high school degree reflecting racial disparities in educational attainment according to orfield and lee more than 60 of minority students attend high poverty high schools compared with 18 of white students the disparities in funding and access to resources can lead to lower quality education putting minority students at a disadvantage for future opportunities mayors can promote education policies that focus on equality of opportunity for example mayors typically have authority to replace an elected school board to raise urban school performance and student achievement mayors can also take steps to collaborate with school leaders to keep classroom sizes down fund programs to ensure students have meals and that their mental health is attended to raise money and create cabinets of representatives from school boards teachers unions and other community leaders to help brainstorm ways to create a citywide culture that better supports student learning economic health an outcome variable in our model this construct represents the strength of a citys economy to mitigate endogeneity the urban institute relied on indicators of economic health that tend to have inclusionneutral economic growth measures that is racial inclusion and economic health covary as exogenous constructs but not because of endogenous collinearity for each observable variable indicating economic health raw scores were collected and converted by urban institute to zscores reflecting the relative score of each city on the variable in comparison to the full 274 city sample thus economic health is measured as an index or average zscore across four indicators chosen by the urban institute the zscore was computed by urban institute such that a high score represents better economic health employment growth the first indicator variable of economic health is employment growth this measure represents the percent change in the number of people who are employed in the labor force from 10 years prior 11 the urban institute included employment growth in the economic health index because employment growth is beneficial for a citys economy in multiple ways contributing directly to its gross domestic product mayors can promote employment growth through workforce development policies for example city policies can broaden economic opportunities for urban residents by enhancing demand and job supply raising demand for certain groups improving the qualifications of workers and augmenting job attractiveness unemployment rate the second indicator variable of economic health is the unemployment rate this measure represents the percentage of residents who wish to participate in the labor force but cannot find employment federal reserve chairwoman janet yellen stated that the unemployment rate is the best single indicator of current labor market conditions a high unemployment rate has negative consequences for economic health of cities directly reducing its gdp it has long been argued that the unemployment rate also captures the degree of job insecurity as well as inequalities in employment the urban institute included it as a measure of economic health because when labor is fully employed economic output cannot grow faster than productivity unless companies hire more workers if mayors enact policies that allow wages for lowincome workers to drop while keeping unemployment benefits the same on average more people will leave their jobs 3 in this way employment growth and the unemployment rate are not necessarily two sides of the same coin but together they offer a more complete picture of a citys local economy housing vacancy rate the third indicator variable of economic health is a housing vacancy rate which indicates housing demand and location desirability it is calculated by dividing the percent of units for sale or rented by the number of sold but unoccupied units it was chosen by the urban institute to measure economic health rather than monthly rent or home sales values as it tends to be the first indicator of a shifting market a high vacancy rates signals poor market conditions and low landuse efficiency sometimes infrastructure growth can exceed actual urban needs resulting in unutilized capacity other times lack of economic opportunities creates urban shrinkage resulting in abandoned housing housing vacancies introduce safety issues as conditions become conducive to crime and reduce a citys tax base which can negatively affect the economy mayors can impact vacancy rates by reducing sale time of vacant properties demolishing unsuitable buildings altering eviction policies funding programs to rehabilitate properties and streamlining permitting processes median family income the fourth indicator of economic health is median family income representing a families relative prosperity or economic wellbeing within a city over the past 12 months 12 median family income is influenced by multiple factors eg occupational structure and industrial mix educational and gender composition of the workforce and disability status of a citys population according to manduca in 1968 … the median family income of african americans was 57 percent that of whites in 2016 after almost 50 years of antidiscrimination legislation attempts to equalize access to education and cultural change it was 56 percent this gap persists despite disparity reductions in education attainment life expectancy and improvement in racial attitudes toward minorities another reason for the persistence of a racial income gap is the shape of the income distribution itself as a disproportional shift has unfolded with a drastic increase in the share of economic resources going to the very wealthy combined with income stagnation for rest of the population this has disproportionally harmed minorities who remain overrepresented in the low side of the income distribution mayors can take steps to improve family income eg by increasing minimum wages enacting guaranteed income programs improving lowcost city transportation and lowering other cost of living control variables mayor race we included this control variable to estimate the role of gender more accurately as a mayors race could influence the priority level placed on inclusion 13 a research assistant blind to the hypotheses coded mayors race to align with urban institutes definition of residents of color as defined earlier in this article pictures and biographies available online were used to code mayor race of the 971 unique mayors in the dataset 92 were coded as a person of color term length prior leadership research as reported in bernerth and aguinis commonly controls for tenurerelated variables to account for differences in accumulated knowledge and experience moreover because mayoral electoral cycles vary by city there are differences across mayors relating to the amount of time each had to enact policy changes before the measurement time point for example if a mayor was elected in 2010 for the 2013 inclusion and economic health numbers she would have had 3 years to enact changes that might impact those measures thus we control for the mayors term length prior to the year of measurement by subtracting the year of measurement from the first year in office 14 12 the urban institute elected to use family rather than household income because family is the typical economic unit family financial decisions are made jointly and family income level better gauges economic outlook than household income as households could be a group of individuals who do not share joint finances to a great extent 13 we thank our anonymous reviewer for this suggestion 14 we use this calculation rather than total term served to avoid counting years in office after the measurement point for example a mayor who served from 1998 to 2005 would have 2 years to enact changes impacting inclusion and economic health in 2000 but their total term served would have been seven years instead of controlling for seven years we control for the two years leading up to the measurement year as the last 5 years could not have impacted outcome measures in the year 2000 political affiliation because political affiliation differentially affects policy decisions we controlled for the mayors political party specifically we coded the mayors political affiliation as democrat republican or nonpartisan of the 971 unique mayors in the dataset 48 were democrat 20 republican and 32 were nonpartisan city population smaller cities tend to be more inclusive on average and the greater the city population typically the more complex it becomes for leadership to navigate issues related both to racial inclusion and economic health moreover the greater a citys population the faster it can experience economic growth and offer economies of scale for these reasons we include city population from the us census bureau as a covariate percentage of people of color the percent of a citys population who selfidentified as persons of color impacts inclusion and economic health mayors with more diverse cities manage more complexities in achieving inclusion and equality of economic prosperity analytical procedures given our interest is examining how gender a categorical variable relates to quantitative outcomes we tested our model with analysis of covariance using a linear mixed effect model with centered regressors for gender 15 lmem is a form of hierarchical linear modeling that uses restricted maximum likelihood to account for nonindependence by parsing out random effects to obtain the leastbiased estimates of the fixed effects the data included clusters of cities nested within states mayors nested by name to account for nonindependence if the same mayor served at multiple data points and citystate observations nested by year this parses out random variance in inclusion and economic health related to city and state as well as macroyear factors reducing error in the individuallevel fixed effect estimate for example cities might differ on broad measures of racial inclusion and economic health and inclusion of a random intercept for citystate makes it explicit that these differences across levels could impact the criteria moreover including a random intercept for mayor name accounts for nonindependence in outcome measures if the same mayor served in multiple terms rather than treating the same mayor at two different time points as separate individuals including a random intercept for year accounts for macrolevel influences that impact economic health and inclusion of all cities said differently a model without random intercepts would assume that racial inclusion and economic health across cities years and mayors would be expected to have the same variability this assumption is likely untenable for the mediation analysis we followed baron and kenny procedures we first tested the link between mayor gender and economic health then we examined the relation between mayor gender and racial inclusion we followed this with the full mediation model in which racial inclusion is added as predictor variable for economic health preacher and hayes advocated bootstrapping to compute a confidence interval for indirect effects thus we used the imai et al mediation package in r which relies on a quasibayesian approximation using 1000 simulations to estimate confidence intervals and significance levels for the indirect effect total effect and proportion of effect mediated results confirmatory factor analysis of the measurement model we first verified whether the indicator variables loaded onto the constructs of interest to ascertain the appropriateness of using the index measure for construct validation of the comparative racial inclusion index we ran a cfa grouped by year to test if the four inclusion variables indeed manifest racial inclusion goodness of fit indices indicated data fit the 15 we center categorical variables to test main effects the lmem coefficient for gender and statistical significance level in the models is identical under both coding schemes center coding has an added benefit of interpreting the intercept as the predicted dv level at the average level of all predictors in contrast in a dummy coding scheme the intercept is interpreted as the predicted dv value for the reference group at the average level covariates the lmem coefficient for the predictor under both schemes provides the estimated change in the dv going from one group to the other as the numerical difference in assigned codes between gender groups remains one under both coding schemes measurement model 16 table 1 presents the mean standard deviation and pairwise correlations for each racial inclusion indicator variable for construct validation of the economic health index we ran a cfa grouped by year to examine if the four economic health variables indeed manifest economic health goodness of fit indices indicated data fit this measurement model 17 table 2 shows the mean standard deviation and pairwise correlations for each economic health indicator variable preliminary results table 3 presents descriptive statistics and bivariate correlations the three focal variablesmayor gender racial inclusion and economic healthwer significantly correlated the direction of the correlations suggests that cities with female mayors on average were associated with greater racial inclusion and better economic health the bivariate correlations likewise supported our rationale for inclusion of the control variables as mayor race mayor political affiliation mayor term length city population and person of color percentage were significantly related to economic health and all but mayor race were significantly related to racial inclusion as the covariates are not focal variables we do not speculate on the direction of those correlations table 1 means standard deviations and pairwise correlations for racial inclusion indicator variables m and sd represent mean and standard deviation respectively of the raw scores where lower numbers indicate greater racial inclusion overall m and sd are represented outside the parenthesis and femaleled cities m and sd are shown first in the parenthesis and maleled cities m and sd follow the pairwise correlations were calculated using 1185 observations the correlations reported on the left without parentheses are the raw score correlations and those reported on the right within the parentheses represent the zscore correlations m and sd represent mean and standard deviation respectively of the raw scores overall m and sd are represented outside the parenthesis and femaleled cities m and sd are shown first in the parenthesis and maleled cities m and sd follow the pairwise correlations were calculated using 1185 observations the correlations reported on the left without parentheses are the raw scores correlations and those reported on the right within the parentheses represent the zscore correlations p 0001 1 because these are pairwise correlations that do not account for year fixed effects the negative association between raw employment growth and raw median family income is driven by macrolevel changes in the labor market that unfolded over 35 years for instance median family income trended up 0034 goodness of fit 0990 cfa results using raw scores of indicator variables comparative fit index 0987 standardized root mean square residual 0034 goodness of fit 0999 17 cfa results using zscores of indicator variables comparative fit index 0978 standardized root mean square residual 0028 goodness of fit 0986 cfa results using raw scores of indicator variables comparative fit index 0977 standardized root mean square residual 0028 goodness of fit 100 test of hypotheses following ancova procedures to test the unique relationship between mayor gender and the outcome variables we parsed out the covariance between control and outcome variables the mediation procedures outlined by baron and kenny examine four key conditions gender effect on economic health gender effect on racial inclusion racial inclusion effect on economic health when controlling for the effect of gender on economic health and the effect of gender on economic health disappears or becomes significantly smaller when statistically controlling for the effect racial inclusion on economic health table 4 reports the ancova model results testing all four conditions of mediation with the full dataset table 5 reports the ancova model testing all four conditions of mediation with a constrained dataset in which we only included mayors who were elected to office at least four years prior to measurement of the criterion variables 18 of the control variables city population significantly related to economic health in both models such that larger cities were associated with a higher economic health index h1 was supported in both the full and constrained models as mayor gender was significantly related to economic health such that cities with female mayors were associated with better economic health than cities with male mayors to test the second condition of mediation whether mayor gender relates to racial inclusion we included median family income as a covariate to account for the possibility that cities with higher racial inclusion index scores were in places where people of color were pricedout instead of cities where they are present in reasonable numbers and included in civil and economic life 19 city population person of color percentage and median family income significantly related to racial inclusion such that more populated cities and more diverse cities had worse racial inclusion scores and cities with higher family incomes had better racial inclusion outcomes supporting h2 mayor gender significantly related to racial inclusion cities with female mayors were associated with better racial inclusion than cities with male mayors for the third and fourth conditions of mediation city population and person of color percent remained as significant control variables related to economic health supporting the m and sd are used to represent mean and standard deviation respectively overall m and sd are represented outside the parenthesis and femaleled cities m and sd are shown first in the parenthesis and maleled cities m and sd follow the pairwise correlations were calculated using 1185 observations racial inclusion index and economic health index were calculated such that higher scores represent better outcomes p 010 p 005 p 001 p 0001 a 05 female 05 male b 05 person of color 05 white c 05 republican 0 independentnone listed 05 democrat we used four years as the time lapse because it is common for a mayors term to be four years thus reducing the dataset to mayors who were in office four years prior to outcome measurements ensures the mayor had on average about one full term to influence the outcome variables ensuring temporal precedence of mayor gender 19 we thank a reviewer for this suggestion third condition of mediation racial inclusion was significantly and positively related to economic health supporting the fourth condition of mediation the gender association with economic health became marginally significant when racial inclusion index was added as a predictor in the model together both the full and constrained dataset appear consistent with a mediation model following tingley et al mediation procedures in r we assessed the significance of the indirect effect of mayor gender on economic health through racial inclusion to test hypothesis 3 as reported in table 6 in both the full and constrained dataset the indirect gender effect was significant the total gender effect was significant the direct gender effect became nonsignificant when the mediator was controlled for and the proportion of the gender effect mediated by the racial inclusion index was significant these findings indicate that the data are consistent with the hypothesized mediation model supporting h3 these relationships as estimated from the constrained dataset are illustrated in fig 3 because these panel data are correlational to mitigate reverse causality and alternative explanations we performed several robustness checks by crosslagging the data backward first we confirmed that mayor gender in year t was unrelated to economic health in year t1 and unrelated to racial inclusion in year t1 categorical variables were unitweighted and centered and continuous variables were meancentered p 0001 p 005 a 05 female 05 male 20 next using a generalized linear model with the binomial family and logit link function and controlling for citystate and year fixed effects we confirmed that economic health in year t1 was not a significant predictor of mayor gender in year t nor was racial inclusion in year t1 a significant predictor of mayor gender in year t this mitigates reverse causality by showing that a more racially inclusive or economically healthier city was no more likely to elect a female mayor compared with other cities discussion we built on fla literature and integrated it with ethics of care to conceptualize how women leaders might achieve urban revitalization fla findings guided our first hypothesis that female mayors might be more effective than male mayors in managing the urban revitalization crisis we next proposed and empirically tested the mediating role of ethics of care leadership in the relationship between womenled cities and urban revitalization ethics of care leadership parts ways with traditional thinkbusiness thinkinclusion expectations ie more money leads to more prospects and benefits will be naturally shared equally it shifts the focus to a leaders ethics as the principal guide for action in revitalizing urban areas ethics of care leadership views the interests of those caring and those caredfor as interwoven and it nurtures inclusion among residents as a path toward achieving economic health results from 272 us cities over nearly four decades revealed that cities with female mayors were associated with greater racial inclusion and better economic health than cities with male mayors mediation analysis supported ethics of care as a pathway to a fla as better economic health in womenled cities was explained by their association with greater racial inclusion these findings make several contributions first scholars have been calling for leadership research to take on a greater role in addressing social issues we extend a fla to urban revitalization and in doing so contribute to emerging research that examines how leadership effectiveness can transcend financial contributions to organizations extending significant societal impacts as well preferences for women leaders during an organizational crisis have been documented but categorical variables were unitweighted and centered and continuous variables were meancentered p 0001 p 001 p 005 p 010 a 05 female 05 male research on actual leadership effectiveness throughout a chronic crisis that unfolds over time is rarer this distinction coupled with empirical tests of realworld data differentiates between a focus on expectations of leadership appointments and actual leadership outcomes second our backward crosslagged robustness check indicated that more racially inclusive cities and healthier cities were no more likely to elect female mayors in the future than less racially inclusive or less economically healthy cities this finding helps mitigate reverse causality the time lagged design overcomes a limitation of prior research that has relied on a single period to investigate a fla for example without timevariant data it is difficult to empirically disentangle if female leaders are associated with more effective outcomes because of their leadership style or if citizens in femaleled cities differ systematically in some way that contributes to differences in outcomes third our results have reasonable ecological validity regarding urban revitalization of cities because our data were not experimental however causality cannot be inferred typically researchers do not manipulate inhumanities and therefore racial inclusionexclusion experiments would be limited to hypothetical scenarios verification of causal links between urban revitalization and socially situated outcomes will require converging evidence from divergent methods we call for continued research using varied methods to build evidence toward causality between leader gender and leadership effectiveness the data show that economic health in the us has been unevenboth between cities and within them because many cities have seen widening racial inequalities despite economic gains city leaders are increasingly linking inclusion goals to economic health economic growth does not automatically lead to racial inclusion for example poethig et al analyzed economic recovery of four cities after the great recession of 20072009 and found that adopting a shared vision and collaborating across sectors helped promote economic recovery but these actions were not enough to promote racial inclusion leaders who furthered inclusion devoted effort to elevating the voice of minority residents enacted policies that removed barriers and crafted narratives that bound together inclusion and economic growth by linking racial inclusion to economic health more city residents can contribute to the economy and share in the benefits table 6 mediation results this table reports the results of the mediation analysis using the mediate package in r the indirect effect represents the association of mayor gender with economic health explained through racial inclusion where b represents the expected difference in the economic health index when the racial inclusion index takes on the value that it would realize with a female mayor as opposed to a male mayor holding mayor gender itself constant the direct effect represents the expected difference in the economic health index when mayor gender switches from male to female and the mediator is held constant the total effect represents the total association of mayor gender and economic health both indirectly and directly the proportion mediated represents the proportion of the total gender association with economic health that is mediated by racial inclusion these results were calculated controlling for mayor political affiliation term length city population year and percentage of color of city residents limitations and future research first because our data are correlationalarchival no experimental causality can be claimed only patterns of associations though results revealed a pathway from mayor gender to economic health via racial inclusion this study does not reveal specific actions women mayors took that resulted in femaleled cities being associated with greater racial inclusion than maleled cities we theorized that divergences among cities in their degree of racial inclusion manifest because of differences in the embodiment of ethics of care leadership by mayors future research can design randomized experiments to causally tease out links between leader gender ethics of care and urban revitalization for instance an experiment could be conducted that requires participants to act as a leader in a hypothetical scenario aimed at improving economic growth of a city participants could be presented with choices of policies to enact where each policy costs a finite number of resources and participants make choices among policies by spending resources this would force tradeoffs whereby participants have to allocate limited resources to policies they feel represent the best pathway toward city development each policy would have pros and cons described some policies could have a clear undertone of ethics of care leadershippromoting goals related to racial inclusion and emphasizing the downstream impact on local residents other policies could have undertones related to business growth participants could be asked to explain their reasoning after makingchoices participants selections could be analyzed to assess if female participants were more likely than males to choose options associated with ethics of care and to what cost they were willing to go to do so and similar comparisons could be made for options related to economic growth perhaps an interesting comparison would be to examine changes in ethics of care by gender holding preferences for business constant this would further illuminate our findings by revealing whether women leaders care more about communities because they care less for business or if they care equally about business but care more for others on top of it qualitative analysis could be performed on the openended explanations to build nuance in the theory to further explain why females appear more likely to enact ethics of care leadership second although care is a virtue it can come with drawbacks if used in excess an extreme emphasis on care could undermine the volition of those caredfor especially if the care receiver is provided with more care than desired or needed there are degrees of care and there is a fine psychological line between overindulgent care and a perception of pity thus effective leaders strike a balance between inadvertently conveying pity rather than respect for the dignity of those receiving the care this is why the framework was labeled ethics of care rather than just care third the dataset was constrained by the parameters used by the urban institute such as inclusion of only us cities with populations exceeding 100000 in 2016 and time periods spanning 10 13 and 3year gaps thus future research is needed to better understand if the findings generalize beyond us borders outside of populated areas and to other time periods inclusion of 1980 and 1990 in the analysis somewhat mitigates a generalizability concern to smaller cities as many cities in the dataset were less populous at that time nesting the data by year and controlling for population we continued to find evidence of a fla which suggests that fla holds regardless of citysize we included covariates and citystate fixed effects to control for mitigating factors such as existing racial diversity population mayor race and political affiliation but we did not speculate on the direction of those relationships future research could examine whether there are moderating factors that accentuate or attenuate the mediating effect of racial inclusion as it relates to a fla for example length of time living in the city might moderate a fla such that leaders who identify more with their communities and bond with members through lived experiences might be more likely to focus on ethics of care when leading through a crisis moreover future research can investigate the origins of gender differences in ethics of care leadership to more precisely discern whether differences arise from varying degrees of value placed on care as a moral virtue as we suggested or whether these differences relate more to societal pressure on women to conform to gender stereotypes or to a greater likelihood of selecting women who conform to existing norms for leadership roles fourth this study examined the role of leader gender on outcomes controlling for race and political orientation it did not take an intersectional approach by conceptualizing and testing an interactive model among these variables this was an a priori design choice given the deductive nature of this study specifically we sought to examine a fla in the context of urban revitalization by conceptualizing and testing ethics of care leadership as a potential mechanism through which women leaders associate with an advantage it was not an eventfocused study in which race might be more of a main factor considered we encourage future research to build upon the theoretical foundation of ethics of care leadership as described herein by inorpating an intersectional perspective such research should aim to provide detailed theorydriven explanations of why and how gender race and other identityrelated variables interact in relation to ethics of care leadership conclusion most people in the us live in cities as cities grow so do disparities in racial inclusion policies like the fair housing act were passed to increase inclusion but declines in racial segregation have not unfolded as expected revitalizing urban environments is a societal challenge with multiple implications bridging leadership research on a fla and ethics of care theory in moral psychology we proposed that mayoral leadership based on ethics of care balances the focus on racial inclusion and economic growth in the cities as a sustainable direction going forward on the basis of data from 272 us cities at five points in time and multiple measures of key constructs we found that cities with women mayors were associated with greater racial inclusion and better economic health and mediation analysis revealed that racial inclusion was one mechanism through which women mayors impacted economic health these results from a setting with realworld complexity indicate that the urban crisis is a challenge that can be meaningfully addressed by leadership and ethics research

growing evidence suggests the presence of a female leadership advantage fla such that women leaders tend to be associated with more effective outcomes in uncertain conditions however mechanisms linking womens leadership to effective outcomes are less well understood we integrate fla insights with ethics of care philosophical framework to conceptualize how women leaders achieve effective outcomes in the context of the urban revitalization crisis in the united states we propose and empirically test the mediating role of ethics of care leadership in the relationship between women mayors and economic health of their cities we used data from the urban institute that includes 272 united states cities and measures of variables in our conceptual model at five points in time spanning 36 years n 1185 cityyear observations we capture ethics of care leadership focused on racial inclusion with an index measure of a citys racial spatial segregation homeownership gap poverty gap and education gap and we capture economic health with an index measure of a citys employment growth unemployment rate housing vacancy rate and median family income we found that femaleled cities were associated with better economic health and this association was mediated by femaleled cities association with greater racial inclusion ethics of care leadership appears to be one pathway through which a fla manifests itself in the context of the urban revitalization crisis this underscores the importance of city leadership that balances social and economic prerogatives implications are discussedsocial inclusion respect care and justice are at the heart of the ethical city barrett et al 2016 p 5

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introduction racism has been intertwined with humans throughout history whether its the massacre of the native americans or the atlantic slave trade in response countless research on the causation and effects of racism has been conducted to gain an understanding of such a persistent issue it is important to note that there have been many works especially studies based on times before the postmodern period that focus on the biology of human variations and their subsequent ties to racism in comparison there has been significantly less attention on the social cultural or historical aspects of racism it is simply illogical to assign all or even most of the underlying cause of racism in modern society to biological differences r perry concluded from biological research that two people in the same population differ more genetically than the difference of the collective genetic makeup between two populations 1 considering the war on terror and the subsequent islamophobia there are many comedic videos circulating the internet where a stereotypical arab presenting person pulls out a backpack in an airport resulting in the people around the person screaming and running away out of fear of a terrorist attack it is easy to conclude such humor on racism towards arab people but theres a more fundamental rationale embedded within these jokes the connection and correlation made between certain practicesculturesreligions with race in these videos there are no indications of the arab presenting man being a muslim nor are there any objective reasons for people to believe hes a terrorist yet the islamic religion and the action of terrorism are somehow tied with his biological feature resulting in racially motivated actions of the people around him this racism didnt stem from ideologies that considered arabs inferior or inherently dangerous instead this racism stemmed from the cultural and social assumptionsstereotypes surrounding his biological features racism is no longer biological its cultural hence the purpose of the research is to look into the cultural aspect of racism in society after world war ii and examine the impact of this relatively new form of cultural racism in europe south africa and the united states the history from biological racism to cultural racism it is indisputable that the history and early forms of racism started based on biological differences whether its body structure skin pigments or fingerprints however why did the concept of race stand out amongst all the other biological differences between different populations considering the fact that there arent two completely identical individuals the huge amount of differentiation between people is simply too big for any categorization to be made thus humans are reduced to using broader and more general criteria to categorize different populations into separate inclusive groups 1 these separated populations of humans influenced by ethnocentric ideals were under the assumption of the superiority of their own groups and conflict arises when major interaction occurs take the example of the development of racism in europe the term race was very rarely used in the context of referencing the skin color of a person before the sixteenth century however in the few hundred years afterward the age of exploration brought the first largescale contact between europeans and the previously unfamiliar populations of the rest of the world africans native americans and asians these contacts saw the emergence of racism based on biological differences as certain races are deemed inferior in nature some of these notions of racial inferiority are result from religion in the bible where noah pronounced a curse on ham which turned his skin black and condemned his ancestors to perpetual slavery to the descendants of shem and japheth the passage was used as almost a pseudoscience proof of people with black skin are naturally inferior the cattle slavery performed over the atlantic slave trade reflected the dehumanization of black people where they are considered to have the flesh of beasts and are treated as such in south america christopher columbus described the hair of the natives he encountered as that similar to horses tail and horse hair showing the equivalence he drew between the natives and animals in these cases racism purely stemmed from the notion of racial inferiority there was no more justification than the simple assumption that certain races are superior toothers which was rooted completely in biological traits and differences this biological racism can be seen in many examples of attempts to maintain race purity in the american south under the jim crow laws interracial marriage was banned due to fear of sexual contamination whites were simply not allowed to form sexual relations with any black people or people with african ancestry 2 in nazi germany the nuremberg laws of 1935 prohibited any marriage and sexual relations between jews and gentiles in an attempt to maintain the purity of the aryan race once again these racist actions solely stemmed from the biological inferioritysuperiority of each race however in the past few decades the concept of ethnicity started to gain more and more popularity among academic scholars there is an important distinction between the term ethnicity and race that needs to be stressed race simply refers to the biological and genetic characteristics of certain populations while ethnicity goes beyond physical appearance and includes culture religion surnames and many other aspects of different populations this new concept is an interesting shift from the purely biological idea of race as the concept of ethnicity in addition to the biological concept of race also bears resemblance to the idea of culture it is a mix of biologicalgenetic and cultural factors some writers such as ashley montagu have advocated using ethnic group as a replacement for the word race 3 this development of race is a significant turning point that led to racism in postmodern society where traditional biological racism has disguised itself and transformed into the discrimination of culture the racial genocide against jewish and other racial groups committed by the nazis during world war ii horrified the rest of the world the sheer amount of pain and suffering hitler and his racial superiority ideologies brought to the entire world resulted in a significant backlash against the idea of genetic superiority the notion of a certain race is biologically and naturally superior or inferior is no longer supported by the public view which signifies that the oldfashioned racism as discussed in the previous examples from the preworld war ii time period is no longer a justified reason for unequal treatment and discrimination in europe the traditional view of the white race being the chosen racethe superior race are no longer easily sustained within mainstream ideologies and regimes of representation 4 in the united states the civil rights movement challenged the historical racism where black people were considered inferior by birth equal rights movements such as the right to vote the right to representation and desegregation all pushed the traditional agenda of biological racism away from public support the passing of the 14th amendment which guaranteed equality to all racial groups in the united states signified the biological form of racism was no longer acceptable in the united states in a larger scope the new social movements of the1960s the feminist postcolonial and postmodern discourses in the1970s the critical forms of popular culture in the 1980s and the new ethnic groups challenging liberal pluralism in the1990s all pushed for the formation of global de jure equality in the postmodern period 4 this massive change in society and the societal perception of racial inferioritysuperiority forced whites to find ways to deny or reframe the white superiority that still existed in society as the whites in the 1960s and 1970s werent able to openly show their racist ideologies on biologicalgenetic superiority they disguised their racist ideologies as criticism and prejudice towards cultural differences between them and other races 5 6 racism has adapted to the new mainstream view of the world and renewed itself in a different format the object of racism is no longer the individual man but a certain form of existing and such a form of existing is inherently tied to culture 7 researchers from the united states western europe and australia have argued that this new form of racism has emerged and is expressed openly to deny the persistent issue of racial inequality in society 8 9 10 6 11 this form of racism tied with cultural differences is a subtle 6 sanitized 12 covert 5 13 8 and symbolic 9 substitute for the globally denounced geneticbiological racism which produces racist effects in a seemingly nonracist way many researchers in australia 14 britain 15 12 western europe 5 6 and new zealand 16 have noted in their papers about the rise of this new form of racism based on and expressed as criticism of cultural differences take the example of new zealand researchers wetherell and potter when analyzing new zealands white populations view and perception of the native māori population claimed that culture discourse therefore now takes over some of the same tasks as race it becomes a naturally occurring difference but this time around the fatal flaws in the māori people do not lie in their genes but in their traditional practices attitudes and values 16 another example is the development of racism in europe after world war ii as mentioned previously the backlash of world war ii denounced all notions of genetic superiority hence biological racism however due to the width and depth of european influence through global expansion and colonization the major part of the global mainstream culture originated from europe this gave europeans the power to deem the western and white culture as progressive and modern while accusing noneuropeans and other racial populations as traditional and backward 17 the stereotype of asians eating disgusting food such as ants and scorpions while snails are considered a fancy dish in france is a prime example of this new form of cultural racism in these cases europeans and white people are no longer viewed as racially superior but rather they are viewed as culturally superior racism becomes cultural social effect of cultural racism as racism transforms from biological to cultural consequent impacts on society followed when analysing the phenomenon of cultural racism it is important to remember that cultural racism isnt completely independent from the oldfashioned biological racism rather it is an evolved version of racism the racism 20 therefore since the entire concept of cultural racism was formed to continue biological racism in a more acceptable way cultural racism bears the same role as biological racism just like skin colors and other biological features culture also creates different and separated groups which can be easily exploited and used as justification for racial discrimination racial discrimination in the postmodern society is no longer based on the ideals of genetic inferiority of certain races but rather modernday racism is justified under the belief that people with different cultural backgrounds and identities especially ones from areas with different religious environments indisputably carry cultural identities that are inherently different from each other this process externalizes people from outside of each cultural group and deems them as others aliens foreigners and strangers putting different cultural groups in if not opposite vastly different positions this process is generally aided by the creation of stereotypes of different cultural groups such as the association of terrorism with arabs mentioned in the introduction section of this paper these stereotypes come together to create static and fixed cultural identities for each cultural group making it as hard for an individual to change their cultural label as it is for them to change the color of their skin this process of externalization and stereotype creation justified the notion that the deepseated cultural differences 18 between two cultural groups are extremely polarized and that the two cultures would not and should not be able to mix with each other just like the colorization of skin pigments cant suddenly change their color in this case people with different cultural labels are considered not culturally assimilable 19 to a society with a different culture and it would be impossible for the prevailing culture and its people to coexist with such deviants to an extent deviants who attempt to join a different society are considered unable to adapt and integrate to a different culture and are thus considered hazards and dangers to society one prime example of this externalization process is the restriction on immigration in many countries in europe images were evoked of british culture being swamped by immigrants 20 thus justifying a new and more restrictive immigration policy in order to prevent the otherwise inevitable cultural conflict in the united states one of the main arguments that support more restrictive immigration policies is that many immigrants fail to learn english and adapt to the american way thus necessitating more restrictions on immigration so the united states doesnt turn into mexico 21 this discrimination against culture is also aided by a fear of cultural contamination refer back to the prominent idea of race purity in biological racism mentioned in the previous section the reasoning and intention behind the illegalization of interracial marriage in the american south as well as the ban on marriage between jews and gentiles in nazi germany are the same in nature as the attempt to maintain cultural purity the fear of mixing two separate cultures and creating a hybridization as known as mixophobia perpetuates the hostility between different groups with different cultural labels cultural racism in different regions cultural racism in europe one of the most classic examples of cultural racism is europe with the commonplace action of adopting cultural racism and somewhat antiimmigration views researchers have argued that racist thinking in modern europe is expressed as the belief that europeans and european countries have a superior culture 22 countries such as denmark has a discriminatory housing quota for ethnic minorities as well as a low tolerance threshold for refugee 23 many european countries also lack coherent or effective antiracist legislation which allowed many demonstrations of its racist and discriminatory ideologies europes racist and discriminatory actions especially those towards immigrants and refugees are deeply rooted in the concept of cultural racism discussed in the previous section immigrants are viewed as the stranger inevitably perpetuating the externalization of ethnic minorities people who look different under cultural racism are viewed as others or permanent strangers who can never adapt and assimilate to the modern and civilized society of europe due to their cultural differences 24 the nexus question is to analyze the reasoning behind this form of cultural discrimination and cultural racism in europe the once relatively liberal refugee policy of many european countries such as sweden and denmark shifted significantly in the mid1980s in response to the ongoing economic crisis and a huge surge of refugees from the middle east the surge resulted in a high number of refugees from muslim countries thus resulting in immigration being considered as muslim invasion 25 it is important to point out that muslim isnt a race or biological identity as it is inherently tied to religion and culture however this fear and hostility against islam led to hate and aggression towards all arabpresenting people the concept of muslim invasion combined with the already existing muslim refugees in europe and the growing antimuslim discourse perpetuated a huge antimuslim discourse as mentioned in previous sections the new concept of cultural racism gave europeans a new justification for their superiority cultural superiority with this ideology of cultural superiority muslims along with other ethnic minorities and immigrants were demonized and vilified the modern and civilized europeans were pitted against the other refugees immigrants and ethnic minorities who are deemed as barbaric tyrannical and fundamentalist 26 thus it was justified for europe to implement more restrictive and discriminatory policies as it is reasonable for a culturally superior population to reject and abuse a culturally inferior population there is also an interesting parallel between cultural and biological racism just like biological racism believes that race purity needs to be preserved cultural racism also creates the idea that culture purity needs to be preserved in this case cultural exchange between the superior white europeans and inferior racial minorities is seen as cultural invasion and contamination by the inferior culture the fear of paris becoming the new mecca creates a societal hostility towards arab immigrants causing discriminatory policies to keep the superior culture of europe pure and safe from contamination of the inferior islamic beliefs and culture this irrational fear of cultural contamination and cultural invasion becomes another prominent part of cultural racism in europe thus the notion of cultural superiority which is in essence the same as the concept of genetic superiority along with the fear of cultural invasion and contamination perpetuated the belief that the pure and superior european culture is under threat from globalization immigration refugees and in general alien cultures subsequently discriminatory measures and actions were taken by european governments to prevent this cultural contamination and to preserve the purity of european culture resulting in cultural racism of europe cultural racism in south africa the racist situation in south africa is a great example of the global shift from biological racism to cultural racism and its subsequent impact in 1948 the pronazi afrikaner nationalists rose to power at that time the horrors and pain caused by the holocaust along with global movements that called for equality made ideologies such as genetic superiority harder and harder to articulate therefore following the mainstream shift from biological racism to cultural racism afrikaners such as henrik verwoerd started to adopt the new idea of cultural racism in the system of apartheid separation based on cultural differences 27 this mindset still upholds the idea that white people and westerners are innately superior to black people and africans on the ground that whites are culturally superior and more civilized than blacks this cultural superiority is combined with religious superiority the south african government claimed christian nationalism as the civilized religion and justified white superiority and the black population was divided into separate tribes that lived on separate homelands this process of creating separate tribes is similar to the actions of belgium when it divided the rwandan population into hutus and tutsis which resulted in severe conflicts and the horrific rwandan genocide in this case the separation of tribes by the south african government purposefully divided the black population of south africa into separate groups which almost forced cultural labels on them as each tribe is governed by their own superstitions this notion of tribes further perpetuated the notion of black people being culturally inferior to white people since afrikaners ruled a nation while africans ruled tribes racism changed again when the world became more and more integrated as the system of apartheid ended in 1990 cultural racism in south africa became increasingly subtle to deny the continued existence of racism in south african society cultural stereotypes were made about black people in order to avoid the accusation of racism discrimination and inequality that stemmed from racism are now characterized as actions caused by cultural differences the cultural differences and stereotypes even though most are resulted from the long history of racism are now used as criticism towards the black population in general and function as attacks towards black people replacing straightforward racist insults cultural racism in the united states the transformation of racism in the united states is one of the most classic examples it is common knowledge and understanding that the united states has a long history of biological racism based on genetic superiority as late as the 1940s comments such as a negro is different from other people in that hes an unfortunate branch of the human family who hasnt been able to make out of himself all he is capable of from a white newspaper editor was allowed to be spoken publicly however with the de jure equality and progress gained by the civil rights movement since the 1960s such forms of racism can be rarely seen in the united states instead the new form of cultural racism expressed in stereotypical claims such as blacks have too many babies and mexicans dont care about education 28 is used to criticize racial minorities in the country and justifies a rationale for blaming minorities for their social status these stereotypical cultures that are currently being forced on racial minorities cause significant difficulties in implementing policies to aid racial minorities a huge factor in the current situation of racial minorities in the united states is the lasting impact of biological racism policies such as racial segregation denied many talented racial minorities from improving their life and status and under the current social standards that inherently prioritize white cultural attributes black peoples cultural performances are hugely devalued causing black people to constantly perform worse than white people 29 however cultural racism aided by stereotypical and pseudo cultures of racial groups blames the current situation of racial minorities entirely on themselves the residual effect of the long history of racist policies is completely ignored here takes the example of the african american population on average african americans have lower levels of parental socioeconomic status and are less likely to be able to convert their education into higher occupational status 30 in a study conducted by jason n houle the findings showed a consistent blackwhite disparity in student loan debt on average african american students have 51 more student loan debt than white students 31 furthermore black people with highincome tend to live in poorer areas than white people with highincome 32 and even black political candidates are facing many unwillingness to vote for them 33 this demonstrates that the current social situation is the prominent reason for the difficulty of black success in the united states rather than the baseless lazy culture of african americans however cultural racism paints over this reality and claims the reason that a huge portion of the black population is living in poverty is that black people are lazy and dont try this baseless and stereotypical view of the culture of racial minorities is used to deny any policy actions that are designed to specifically aid racial minorities such as affirmative actions and other welfare acts this refusal to give more benefits and aid to racial minorities creates cyclical hardships for racial minorities studies had shown that around 60 of black men who didnt have a high school education have been incarcerated at some point in their lives 34 this resulted in the deeply rooted psyche of the black ghetto and dangerous black male in american society creating false stereotypes such as black people use more drugs than white people and that all black communities are prone to drug crime 35 36 37 this false notion of black culture and the results of ignored racial inequality is further used to put more blame on african americans which once again denies targeted aid towards to them this creates an endless cycle of racial minorities being blamed for racial inequality unable to receive any aid and opportunity to improve their situation and being blamed again for their situation thus cultural racism along with stereotypical cultures of racial minorities functions as a barrier that traps racial minorities in the same situation as biological racism had put them in it is used by whites to maintain racial inequalities in the status quo and prevent any changes that will clear out some of the residual effects of historical racism with that cultural racism becomes a tool for whites to be racist and press down on racial minorities without being blamed for racism and thus barricades whites from the united states racial reality 28 conclusion the concept of racism first started as a biological notion of superiorityinferiority different populations with different biological features such as skin color all considered themselves as the superior kind leading to a fear of racial contamination resulting in many discriminatory and even violent attempts to protect the idea of race purity however during the postworld war ii period as a backlash from the horror left by the holocaust in world war ii many social movements became prominent under waves of social movements and transformations biological racism was denounced by the mainstream ideology and genetic superiority is no longer a valid justification for racial discrimination as a response to the situation western society shifted to using cultural differences between each population creating a more subtle and sanitized alternative to continue the previous racial discrimination cultural racism functions the same way as biological racism cultural identities are fixed on many racial groups and are used to justify exclusion and discrimination in an attempt to prevent cultural conflict and maintain cultural purity individuals are seen as unable to adapt to different cultures just like individuals cant change their skin color in europe cultural racism presents itself in the form of european cultural superiority justifying discrimination and exclusion of immigrants and refugees in south africa cultural racism is used to rule under the system of apartheid and continue antiblack racism in the united states cultural racism combines with stereotypical cultural stereotypes to maintain the racist status quo and hide the racial reality of the country however it is important to recognize that the analysis and research on cultural racism are not close to being complete there are many criticisms of the concept of cultural racism many argue that many examples used in cultural racism research are simply cases of culturalism which is a concept of culture being the main force that shapes human affairs it is undeniable that the current understanding of cultural racism and culturalism creates many gray areas and overlapping of the two concepts requiring a further study on the relation and distinction between the two concepts historian and antiracist activist george m fredrickson also concluded from his historical analysis that devaluations and discrimination of certain religion is a separate concept with racism 2 thus requiring further data analysis and research to rationalize the relation between the two concepts additionally cultural racism isnt the only factor behind social phenomena and situations individual factors and contextual situations are all causes of the presented situation when analysing situations such as academia and education factors such as gender political view area of interest and many other factors are all independent variables that affect studies outcomes and results therefore future studies should avoid the conventional approach of viewing race and culture as the only independent variables in a situation and include other independent factors as well 38 it should also be pointed out that this paper only took a focus on situations of a few racial groups and didnt examine the situations of groups such as indigenous people in the united states it is important to recognize that cultural racisms effect on indigenous people also needs to be analysed and considered as part of the overall concept of cultural racism just as james v fenelon wrote in his critique of bonillasilvas work future research needs to expand these analyses and include perspectives of indigenous studies 39 furthermore as biological racism has not disappeared completely it is important to do further research on the balance between biological and cultural racism in the current world and analyze the reason for the remaining biological racism in case of suggestions of methods to resolve the current issue of cultural racism researchers should predict and consider the possibility of the formation of a new kind of racism just like the formation of cultural racism as a replacement for biological racism

this paper focuses on the concept of cultural racism a relatively new term that emerged after world war ii the term which is also referred to as new racism postmodern racism neoracism and differentialist racism generally refers to the form of racism that deems one racial group superior over another based on cultural differences not biological differences biological racism believes racial superiority is determined based on physical and genetic features the study takes an indepth analysis of the process in which the backlash of world war ii and following social movements caused the shift from biological racism to cultural racism cultural racism functions the same way as biological racism cultural stereotypes and associated identities are used as justifications for racial discrimination in europe cultural racism presents itself in the form of european cultural superiority justifying discrimination and exclusion of immigrants and refugees in south africa cultural racism is used to rule under the system of apartheid and continue antiblack racism in the united states cultural racism combines with stereotypical cultural stereotypes to maintain the racist status quo and hide the racial reality of the country

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expenditure of more than one billion american dollars 1045b£hrqolshasingle unemployed and low incomeaahfn recommended that nurses should work to understand the factors contributing to enhanced hf selfcare practices in general international selfcare recommendations could not be transformed into saudi context due to difference in individual and cultural characteristics therefore the aims of this study were to describe selfcare practices among saudi hf patients and determine the sociodemographic factors that contribute to selfcare practices the outcome of this study will inform healthcare team as well as contribute to hf selfcare body of knowledge in saudi arabia methods a crosssectional descriptive correlational design was applied the study was carried out in almadinah cardiac center almadinah almunawarah saudi arabia one of 25 heart care centers and departments across the kingdom the study site was selected as a representative of other centers in saudi arabia due to its characteristics in terms of patients number case variety and advanced cardiac services it is a 100bed facility with an estimated 30000 registered patients and 80000 annual outpatient department opd visits the study was carried out in the opd a convenience sampling technique was used to recruit patients with hf who were attending their followup consultation appointments at almadinah cardiac center almadinah almunawarah saudi arabia the sampling approach was adapted from an earlier study in jordan 7 the study included patients who iefn160α005 effect size f 2 015 power 1β 095 and iv7 15 however 270 questionnaires were distributed to compensate for potential invalid or incomplete responses the study protocol was approved by almadinah cardiac center institutional review board no 2020r29strobe checklist was utilized to enhance study methodology the study utilized the arabic version of the revised selfcare of heart failure index schfi v72selfcare10 items9 items plus 2 on patients ability to detect symptoms8 itemsrca higher score indicates more effective selfcare practices2 nursing interns who were trained to carry out data collection interview data collection was carried out in the clinic waiting area potential participants were introduced to the study verbally and given the study information sheet that included the consent form agreeing to participate some who did not wish to sign were included considering their responses to the study questionnaire as consent to participate participants were offered the option to record their responses through the data collection team who documented them in the study questionnaire using paper and pencil completed questionnaires were returned weekly to the researcher duration of data collection for each participant was between 812 minutes statistical analysis descriptive and correlational statistical analyses were carried out using the statistical package for the social sciences version 200 ibm corp armonk ny usasdloaded as subscale in the schfi results a sample of 245 hf participants responded to the survey with an overall response rate of 907 those who did not respond were mainly concerned on the time that the questionnaire may take sociodemographic characteristics table 170 primaryelementary and secondary schools the participants were 56 years old on average had 36 years of disease duration had one hospital admission in the previous year and had 5 family members living with them table 2 shows that the confidence scale was highest 84 295±167 and 224±188 table 3 provides comparisons of means among participants sociodemographic data female participants scored higher in management and confidence than males the mean management scale for females was significantly higher than that of males t 243 229 d031 p00233t 243 309 d042 p0002f 2242 518 p0006 η 2 0041f 3241 406 p0008 η 2 0048 the effect size was small to medium for education level and employment status in the aforementioned results multiple linear regression analysis revealed some significant factors contributing to selfcare practices the total score was not significantly explained by id variables despite it was close to the significance level alpha p0072r 2 0082 f 7237 discussion participants sociodemographic characteristics were similar to earlier national studies in the field of cardiovascular healthcare research for instance the mean age of 56 years and male dominance 70 in this study were within the range of earlier saudi studies 1420 such similarities could be attributed to the hf population which is also presented in international studies 528 therefore the conveniencesampling approach did not change the target population characteristics in general the study result accomplished the main 2 aims that are describing selfcare practices among saudi hf patients and determining the sociodemographic factors that contribute to selfcare practices from the first study aim stand the selfcare maintenance subscale scored 675 and monitoring subscale scored 672 which are higher than those reported in earlier international studies for instance the maintenance subscale was 48 in china 62 in the united states of america and 53 in jordan 29 30 31 the lower threshold of accepted selfcare practices was ≥70 13 in specific continuous healthcare delivery capabilities may keep hf patients under close monitoring this explanation was supported by the significant explanation of the hospital admissions to 85 of the monitoring scale however this may not reflect a high patient engagement approach as much as the healthcare systems monitoring capabilities specifically checking the 2 extra items in the monitoring subscale how quickly did you recognize that you had symptoms and how quickly did you know that the symptom was due to heart failure revealed low scores therefore participants were unable to identify or recognize symptoms because they were dependent on the healthcare system regarding diseaserelated matters selfcare management 75 453±0738public educationv72 and other widely used international instruments is crucial for comparisons between national and international outcomes moreover understanding factors and approaches to engage hf patients participation in their healthcare practices identified as selfcare or selfmanagement is a cornerstone for successful healthcare interventions 36 thus this study may also contribute to a better understanding of such factors among saudi hf patients study limitations the generalizability is limited due to crosssectional design convenience sampling and single data collection location on the other side these factors facilitate smooth hf participants flow to the study location during the study period in addition comparisons with national and international studies revealed acceptable compatibility in terms of gender and age representation this does not preclude the need for further studies with more representative sample utilizing a longitudinal study design from a values are presented as mean ± standard deviation sd significance level at 005 † general education include primary secondary and high school education anova analysis of variance positive perspective the study is a positive step towards addressing hf patients selfcare practices and factors that may enhance their care management and quality of life in conclusion this study shed light on hf patient selfcare practices in one cardiac healthcare organization in saudi arabia participants showed suboptimal hf selfcare practices as well as the confidence to practice selfcare activities female gender education status and hospital admissions were correlated with higher selfcare confidence was a major predictor for all selfcare subscales therefore focusing on building confidence among hf patients could be an area of a priority in healthcare interventions

objectives to describe selfcare practices among saudi heart failure hf patients and identify sociodemographic characteristics contributing to selfcare practicesa crosssectional study utilizing the arabiclanguage version of the revised selfcare of heart failure index schfi version 72 a convenience sample of 245 people treated for hf at a tertiary heart center in the kingdom of saudi arabia were recruited from june to august 2020 results statistical descriptions of schfi showed that confidence level was 84 maintenance level was 675 and monitoring level was 672 females hf management p0023 and confidence p0002 were significantly higher than male participants in addition education level and employment status had a significant effect on hf monitoring with a pvalue of 0006 for the 4 employment categories

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background the syrian crisis has brought to the forefront the enormous challenges that families face in the context of war and displacement to date over 7 million people are internally displaced at least half of those internally and externally displaced are children studies suggest that the mental health of syrians that have been displaced indicate rising levels of psychological distress this is in the context of minimal mental health and psychosocial support services for internally displaced people and refugees in difficult to access areas in immediate humanitarian crises the focus is on shelter food and essential medical care however loss and adversity disruption and adaptation to new environments pose additional significant risks to mental health building resilience and optimising mental health is fundamental to longer term adjustment and reducing emotional suffering and promoting mental health is therefore a major global health challenge systematic reviews show that the key protective factors for refugee children include settling in a stable context with social support parental support and family cohesion perceived support from friends and good experiences in school a review of preventive interventions for children exposed to armed conflict including refugees noted the paucity of highquality research on interventions in these contexts and the need for psychological first aid to be embedded into programmes in primary health and education the scale of the syrian crisis makes plain the impossibility of providing individual interventions for all families at risk of mental health difficulties given the scale of the problem one priority for delivery of psychosocial interventions in this context is to identify ways of providing information at the population level as part of a public health model and evaluating these families represent the front line of defence for childrens mental health promoting preventive approaches which provide information tailored to the community and context to help families provide warm supportive parenting is one means of offering a relatively lowcost method for strengthening support for children however building the evidence base for helpful interventions in highly risky settings requires a feasible means of obtaining data we conducted pilot work on parenting in refugee camps in turkey and syria including focus groups and interviews with 27 parents and two nongovernmental organisation staff in the field questionnaires assessing the mental health of children were also administered to 106 parents and caregivers this work revealed that very soon after the immediate extreme stress of displacement parents were very keen to access information on how best to parent their children in this new context and were making active attempts at reaching support from ngo workers health professionals in the refugee camps as well as seeking advice from other parents they willingly completed brief questionnaires and participated in focus groups where they talked constructively about their needs parents made plain their need for information on how best to care for their children in this context the pilot work made clear the potential advantages of families having access to information to support them in their parenting struggles working with a ngo watan many hours were spent in discussions as to how we could reach families at a population level and low cost we identified several possible means such as reaching families via refugee camp schools or aid distribution points watan suggested that we could distribute printed material rapidly to very large numbers of identified families in need alongside their routine distribution of bread via their humanitarian assistance charity khayr charity foundation and obtain data on parent and carer views through this means this method suggested the greatest potential means of rapid distribution of information and data collection the aim of the study was to test the feasibility of the bread wrapper approach firstly to distribute information to families including both internally displaced persons and existing inhabitants living inside syria and secondly to obtain completed questionnaires from families via the same bakery distribution routes the questionnaires enabled parent feedback on the perceived usefulness of information provided as this approach was entirely novel a check was made on whether there were any significant differences in how useful idps and existing inhabitants found the leaflet methods routine daily delivery of bread from a bakery in syria run by khayr was used to distribute parenting information leaflets and questionnaires to parents and other caregivers living with children in a conflict zone in northern syria close to the turkish border at the time families in the area surrounding the bakery comprised 60 idps and 40 existing inhabitants for many of the idps this was often their second and sometimes third relocation point since fleeing their homes every individual listed as living within 10 km of the bakery received bread routinely regardless of whether they were an idp or existing resident bread distribution was carried out daily by approximately 200 volunteers using frequently updated lists for streets and blocks of housing which included parentcaregiver status and needs and thus households with children could be identified allowing distribution of study materials to appropriate recipients a local project worker was identified by watan to manage the study from turkey study materials and a very detailed specific research protocol were emailed to the project worker in turkey where parenting information leaflets and questionnaires were printed and subsequently transported alongside bakery supplies to the bakery in syria a field officer led the study from the bakery inside syria and coordinated volunteers who assisted in packing and distributing materials there the bakery was 130 km from the bab alhawa border crossing an international border crossing between syria and turkey at the bakery questionnaires numbered and colour coded to enable data tracking across different distribution points plus pens were packed inside transparent plastic bags containing the daily provision of flatbreads three thousand bags of bread enclosing study materials were distributed to families listed as including an adult caregiver of a child or children from three of the bakerys surrounding distribution points these were located within 3 km of the bakery to the north and east the field officer and volunteers then supervised the return of questionnaires into boxes at the distribution points and then to the bakery over a period of 5 days questionnaires were taken back to turkey over 5 days where they were photocopied to prevent data loss and despatched 10 days later to the uk photocopies held in turkey were destroyed confidentially following receipt of the original questionnaires in the uk all stages of the study were photographed to verify activity whatsapp© which allows photographs to be shared and when available email and skype © were used to monitor the progress of the study free text comments written onto questionnaires were translated by the lead author who is bilingual englisharabic leaflets were drawn from a range of sources informed by prior qualitative work with families and practitioners in refugee camps in turkey and syria syrian refuges resettled in the uk relevant information from a range of ngos available online and literature on key components of parenting interventions the leaflet comprised two sides of a4 with four sections what caregivers might be experiencing what children might be experiencing how caregivers can help themselves and how caregivers can help their children the leaflet was reviewed several times by both watan workers as well as a syrian refugee advisory group in manchester before the leaflet was finalised the leaflet and further information is available online pfrgresources questionnaires covered whether and how long families had been displaced basic demographics who caregivers talked to about parenting concerns and then asked specific questions about the leaflet including an overall rating and ratings of each of the four sections of the leaflet on a four point scale not at all useful to a great deal space for comments was provided all materials were translated into arabic with back translation to ensure fidelity approval was obtained from the university of manchesters research ethics committee in addition 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 the protocol and risk assessment was developed with and reviewed by watan and khayr the university of manchester humanitarian conflict response institute and university ethics committee were consulted throughout some of the ethical considerations of working in this context are described separately results parenting information leaflets and questionnaires were successfully distributed over 2 days to 3000 parents and caregivers in total 1500 from the first bread distribution point 1000 from the second and 500 from the third the field officer and volunteers were able to distribute packs and obtained completed questionnaires with no adverse events the return rate overall was 1783 595 comprising 740 for location a 690 location b and 354 for location c in addition 400 respondents wrote comments on the questionnaire table 1 shows the sample characteristics of the respondents 1271 were internally displaced the majority of respondents reported seeking parenting support overall the majority of families both idps and existing residents rated the usefulness of the leaflet as quite a lot idps 774 existing residents 274 or a great deal idps 262 existing 75 the t tests indicated a significant difference on all five usefulness questions between idps and existing residents with idps giving higher ratings respondent comments were coded using a bottomup multistage content analysis process interrater reliability was ensured by a second researcher independently coding the data set and then a third researcher comparing and synthesising the two data sets into one four main themes emerged positive comments about the leaflet suggestions for modifications a description of their childrens needs and the value respondents placed on their faith nineteen comments were coded twice into two separate themes the highest numbers of comments were in the positive comment theme respondents praised the content of the leaflet for usefulness and clarity one caregiver wrote i have been waiting for something useful like this after not finding anyone to answer my questions another wrote this is great if we follow it accordingly it has relaxed us and shown us what to do we can reduce anxiety and fears in our children and make them feel safer messages described increased positivity motivation and caregiver selfconfidence on receiving the leaflet caregivers left comments suggesting what modifications they felt needed making to the leaflet they suggested they wanted more detailed information on emotional difficulties such as anxiety and dealing with bereavement one caregiver wrote i wish there was more attention and details on how to deal with fear our children are really suffering from this caregivers described both childrens physical needs and psychological needs one caregiver wrote the children are complaining a lot now of physical problems and the main reasons for this is the stress they are facing from how global mental health fearful they are during these really challenging times high levels of fear bedwetting and anxiety were the most common psychological problems reported finally caregivers comments contained references and supplications to god such as we turn to god for support some comments were only prayers or reference to god while others ended with a religious supplication discussion this study demonstrates the feasibility of a means of both distributing information and receiving responses which fitted readily into existing humanitarian frameworks the efficiency with which the ngo distributed 3000 leaflets and questionnaires in 2 days and the very high return rate of 595 from families exemplifies the potential that this approach offers for rapid dissemination of information to families and for families to give feedback to our knowledge this is the first time this approach has been used we received photographic reports via whatsapp© on the progress of the study from the printing of materials in turkey through their wait for several days in the bread supply trucks on the syrian border their distribution packed into the supplies of bread for each family to their return via skype © we heard of the cheers of people queuing at the bakery distribution points when parents dropped off completed questionnaires while we do not have exact data on the literacy rates of families who were involved in the study we were informed by our field officer that these were high often if one member of the family was illiterate there was another member in the family who could read and write we received a photograph of a child completing the questionnaire on behalf of his mother who could not read or write a valuable observation for planning the framing and presentation of future resources we were open minded over how valuable caregivers in this context would find the leaflet but were pleased to find that 815 of idp caregivers rated its overall usefulness as either quite a lot or a great deal in addition of the five items caregivers were asked to rate three were rated as quite a lot or more these results indicate the potential for brief written material to assist families in better caring for their children in the challenging environment the comments left by caregivers further supported the usefulness of the leaflet with 69 of the 400 comments being positive several comments expressed thoughts and ideas that were not mentioned in the leaflet such as giving yourself a chance to relax emotionally is very important so that you can take control of your actions and encourage good behaviours in your children it is possible that the leaflet may have prompted parents to think and reflect on their parenting and what strategies they could adopt to better care for their children similar findings were found in our previous exploratory work with syrian refugees simply taking part in conversations about parenting challenges led parents to reflect on how they could improve and adapt the approaches they were using with their children parents wrote very useful and detailed comments too on what modifications they felt were necessary to global mental health improve the leaflet not only is this information very important for future replication and dissemination it also provided further insight into what key difficulties caregivers were struggling with we had included analysis to identify whether there were any differences between idps and longer standing residents it is noteworthy but perhaps not surprising that the families who had been displaced found the information significantly more helpful these were families experiencing high levels of difficulty having had to abandon their homes and the stress of family life in displacement would be expected to be higher putting strain on parenting resources of paramount concern was the safety of all staff and families detailed protocols were designed to cover anticipated risks tragically one bakery we had planned to work with was bombed before the study commenced the area was deemed too dangerous for uk researchers to travel to and the study was therefore run remotely by local staff already in place and well versed in management of daytoday security we were conscious of the risks posed if materials were not acceptable and of the security of the data itself at the ngos request the parenting information leaflets and questionnaires carried no identifying information regarding their source returned questionnaires were photocopied as quickly as possible following collection and crossing the border to turkey and kept separately in case of loss of the original versions during transport to the uk in presenting the data actual locations remain confidential since this study has been completed heavy air strikes in the area mean many of the existing families have now left for turkey and new families have arrived from other parts of syria highlighting the struggle and often constant movement refugees experience in search of safety and the need for support to be accessed wherever they are the field officer highlighted to us the significance of the relationship and trust we had built with the ngo watan and its advantages for the study we had worked closely with watan over the past 2 years on background exploratory research therefore they trusted our teams expertise and research motivation and were eager to support this study likewise we trusted their capability to follow our ethical requirements and execute the study professionally on the ground the families engaged in the study and returned questionnaires as they were distributed from a source they trusted with such vast numbers of bread packs being delivered daily many of those involved in bread distribution were members of the local community who were volunteering their time we had no indications that families were concerned that their confidentiality would be compromised these cycles of trust were paramount a study carried out under these conditions and with a very limited budget has many limitations it was essential to keep the feedback questionnaire brief and not to exceed one double sided sheet of paper in order to ensure low costs and maintain information integrity which could be at risk through stapling multiple sheets therefore there are many questions that we could not explore such as if those that completed the questionnaires were parents or caregivers to the children or how long these children had been under their care also although the majority of those that completed the questionnaires indicated that they were male it is possible that this is not an actual reflection of the responses volunteers informed the research team that many fathers indicated during the return of the questionnaires that responses were actually informed by their wives but that they had indicated male as they had returned the questionnaires the feedback questionnaires indicated that confidentiality will be maintained at all times and no names or identifying materials were requested though there was no indication that families were concerned about confidentiality as they had not raised any concerns with volunteers or ngo workers we cannot be sure that some may not have returned the questionnaires because of this especially in the highly volatile political time that this study was conducted in addition under more secure circumstances it would have been excellent to test whether the leaflet actually brought about any changes in family life over and above the boost to morale so evident in the comments provided by families the demonstration on a large scale of the feasibility of this effective familyspecific communication and research channel helps to establish a basis for the further development and testing of materials to provide psychological support to families which can act as the base layer of a public health approach in a complex changing context where very little psychological assistance is available peltonen and punamaki identify new generation preventive interventions which start from recognition of strengths and vulnerabilities of specific groups and work to enhance existing protective mechanisms and elements that promote healing and resilience attending to culturally salient appreciated traditional ways of addressing distress the development and evaluation of culturally appropriate and evidencebased materials which can rapidly be made widely available for distribution is essential we did not undertake formal cost effectiveness analysis but the overall cost of local printing distribution and collection of questionnaires over and above the ngos preexisting costs for bread distribution was approximately 18 uk pence per family this indicates the global mental health published online by cambridge university press scope for approaches using existing humanitarian supply routes to distribute information across a wide range of contexts and emergencies of all kinds the value of this kind of piggybacking merits much more extensive investigation across low resource settings we have placed the materials developed in the course of the study online to allow open access with some translations of leaflets into other languages the leaflet has already been used with minor modifications for newly arrived families in sweden evaluating the effects of providing this kind of information is now needed evaluating the outcome of interventions in conflict zones is challenging the leaflets were designed to provide some brief pointers for caregivers and the size of any effects that might be promoted is hard to gauge research in low resource contexts shows that even very brief interventions can produce surprisingly high levels of change it was heartening that parents commented that they valued simply having their difficulties acknowledged and the significance of this plus the amount of information needed to bring about change in parent mental health and selfefficacy requires further investigation research studies in more secure contexts need to test changes in for example parental sense of competence and changes in child behaviour and emotional adjustment establishing the minimal level of provision that can bring about significant change under different circumstances and with different levels of need is an important task for the field requiring research methods which can maximise information retrieval in complex humanitarian contexts including for example tsunamis and earthquakes as well as conflicts our aim was to test the feasibility of a novel approach which proved successful testing the effectiveness of materials for use in this context including both impact on individual families and the transmission of information and sharing of support within wider communities is essential the methodology we describe provides a means of providing families with very rapid access to information and researchers with a novel means of collecting data in the field under difficult conditions given the scale of need for rapid response in humanitarian emergencies this approach has the capacity to assist many thousands of people

background risks to the mental health of children and families exposed to conflict in syria are of such magnitude that research identifying how best to deliver psychological first aid is urgently required this study tested the feasibility of a novel approach to largescale distribution of information and data collection methods routine humanitarian deliveries of bread by a bakery run by a nongovernmental organisation ngo were used to distribute parenting information leaflets and questionnaires to adults looking after children in conflict zones inside syria study materials were emailed to a project worker in turkey leaflets and questionnaires requesting feedback were transported alongside supplies to a bakery in syria and then packed with flatbreads three thousand breadpacks were distributed from three distribution points to which questionnaires were returned and then taken to turkey and dispatched to the uk findings notwithstanding delays 3000 leaflets and questionnaires were successfully distributed over 2 days questionnaire return yielded 1783 responses a 595 return rate overall ratings of the usefulness of the leaflet were 1060 595 quite a lot and 339 190 a great deal content analysis was used to code 400 respondent comments four themes emerged positive comments about the leaflet suggestions for modifications descriptions of childrens needs and the value respondents placed on faith interpretation findings indicate the willingness of ngo staff and volunteers to assist in research the remarkable willingness of caregivers to respond and the value of brief advice it demonstrates the scope for using existing humanitarian routes to distribute information and receive feedback even in highrisk settings

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introduction education for women were equal to men in the intellectual field lopamudra the wife of sage agastya was the author of vedic hymns maitreyi used to discuss the problems of philosophy with her husband mundan mishras wife mandavi had even defeted adi shankaracharya in a debate the queen of jhansi laxmibai gained fame as heroines begum hazrat mahal razia sultana and ahilyabai as an administrator the whole society is familiar with noorjahans administration ramas companion sita krishnas beloved radha meerabais spiritual singing and becoming one with krishna revels the form of womens primal power but during the british rule western education was introduced in india which had a unique effect on both hindu and muslim women as a result of the change in their attitude the womens society took a new turn in independent india the decentralization of power in the fields of poltics the abundant reservation given to women and the facility of education turned the game the changed perspective of the indian society and the increasing step of modernization have changed the life of women in many roles and social relations both hindu and muslim women are no longer confined to their families but are playing active roles outside the home for economic gain and personal goals educated women have brought a change in the traditional outlook by joining many jobs and are playing an influential role for themselves and their families and society as a result of increasing steps of social change spread of education political modernization many type of changes are seen in the indian society sitamarhi district is the birthplace of maa janki where the birth anniversary of maa sita is celebrated with great respect even today hindu women could not get the respect which they deserved the condition of muslim women is even more pitiable they are limited to their own families their contribution to the society is negligible the reason behind all this is their low education level and low attitude which is not connecting them with the modern social change logical analysis of all such things and complete conclusion will be tried to know in the research paper presented in modern times the spread of education is happening at a rapid pace and as a result the pace of social change is also fast in the present period in any society when there is a change in social values ideologies institutions social roles patterns of interaction etc then we name this social change change is the eternal law of nature and life social change is also a universal truth this change takes place in the line of indian hindu and muslim women as per their environmental conditions there are many factors of socioeconomic educational cultural and political fundamentals at present different levels of education have not only played a role in social change but have also accelerated the pace of social change especially the change in the psychological and social thought currents of women is visible in its effective form in the light of the new education policy the leading role of todays teacher is to make the subject matter of this research paper present the explanation effectively people of different religions communities and castes have been living in india they have been expressing their attitude in different languages they have different ideologies lifevalues and cultures yet there is uniformity and unity in diversity hindu and muslim are to major communities living in india for centuries comparatively the pace of social change in hindu society has been more rapid than that of muslim society a lot of changes have been taking place in their social educational economic and cultural fields in comparison the transformation of the muslim community did not take place with the speed that was expected the main reason for this has amit anand masood alam khan zakir hussain a comparative study of the attitude of hindu and muslim women their educational level and social change in sitamarhi district 1536 been their indifference towards education the muslim community until recently has been placing more emphasis on religions education received from maktabs and madrassas which have been less concerned with modernity the indian constitution has provided equal civil facilities to both the people of the society yet the muslim society seems to have lagged behind india is a male dominated country since time immemorial the responsibility of the family has been a major challenge before women participation the patriarchy of the muslim society has fixed the workplace of women within the four walls of the house the size of the family of muslim women is generally found to be large she given preference to joint family and her family responsibilities are also more than the women of hindu society in such a situation muslim women were left behind in thinking in the direction of social and political responsibilities due to spending most of their time in the discharge of family responsibilities despite having the ability and capability women play a central role in any family it is the responsibility of the women to nurture the children and provide them proper manners thats what it is said that a woman being fully educated is like making a whole family educated at present in the era of rapid social change women seem to be most affected this change appears to be reflected especially in their attitude ideology and their outlook so we can say that the effect of womens attitude is sufficient clearly reflected in the society changes in the world of women have attracted the attention of sociologists and educationist and teachers have started research work in the light of these facts a lot of research work has been done and is being done on various social economics and educational problems related to womens education and attitude to what extent the attitudes of two different religious hindu and muslim women are different towards the various change happening in the society there are very few research studies on how much equality is there how aware they are about these changes and what has be the impact of the new education policy on their attitudes or what is the role of education and teachers in this therefore this research problem has been chosen to answer theses question pathan while presenting his research paper on the educational backwardness of muslim women said that muslim women are not educationally strong the women of the rural society wanted to get their children married at an early age she hesitated to give more education to her children and did not want to send them out of the house in the women of rural area along with the economics reason the effect of social reasons was also found fatima conducted a research on the women of bangalore city and concluded that education has improved the status of women she is now fighting the social evils in a good way and getting employment to get education she herself is educated and is also educating her children vasuki while doing research on womens attitude towards education found that women of all different classes are quite aware of education they want to make their place in the society by getting alms aggarwal studied the impact of education on the social and cultural modernization of hindu and muslim womens and pointed out that education played an important role in changing the ideologies of femininity this made a serious impact on the customs and traditions which affected both hindu and muslim women he has not seen any effect of age on the consertive thinking of muslim women modern education the objective of the proposed research work is to study the effect of revolution and progress in education due to social change in present times on hindu and muslim women following are some of the major dimensions on which the proposed research paper will highlight1 to study the attitude of hindu women and muslim women towards social change 2 to study the difference in attitude of hindu and muslim women towards social change research method in this research paper descriptive research design has been used the informations datas related to the subject of the research paper has been obtained from secondary sources and their analytical analysis has been done research tools in the proposed study a comparative study of hindu and muslim womens attitude towards social change with reference to their educational level will be done but due to nonexistence of any instrument on this subject a social change attitude scale will also have to be constructed which will be based on likert method the dimension of social change towards which efforts will be made to know the attitude of women in this scale are as follows 1 small family 2 child marriage widow marriage and intercaste marriage 3 religious tolerance 4 educational status of women 5 freedom of job business for women 6 participation in politics 7 women have the right to higher education 8 her role in sports literature and theater hypothesis of research in the context of the above objectives of the research work and research analysis the concept of the proposed research management can be kept in the following forms1 there is a significant relationship between hindu womens attitude towards social change and their educational level 2 there is a significant relationship between muslim womens attitude towards social change and their educational level 3 there is no significant relationship between hindu and muslim womens attitude towards social change and their educational level keeping these causes and consequences in mind due research and testing is the basis for its treatment based on the above reference and practicality this research study will be delimited as follows1 only hindu and muslim women residing in sitamarhi district will be selected for the present research work 2 in this study hindu and muslim women at different educational levels such as illiterate low level educated women medium level educated women and high level educated hindu and muslim women are involved in social change what is the attitude towards is to be studied result and discussion 100 highly educated and medium educated hindu and 100 muslim women living in sitamarhi district were personally contacted for the compilation of data and they were informed about the purpose of the research after that they were given an attitude scale and asked to put a tick in front of any one of the brackets strongly agree unsure disagree strongly disagree made in front of the statements given in it less educated and illiterate women have also been included in this study so data has been collected for these women using interview method based on the search results it can be concluded that the education level of hindu and muslim women in india is generally lower than that of men and other religious groups the following are some key findings from the search results data analysis and interpretation according to a report by pew research center hindu women have the lowest level of educational attainment of any major religious group in the study with an average of 42 years of schooling compared to 69 years among hindu men muslim women globally have an average of 49 years of schooling compared to 64 years among muslim men bano highlights that india has the lowest female literacy rate in asia despite efforts by the government to promote education for all the study also notes that muslim women in india have a lower literacy rate than hindu women siddiqui compares the educational status of muslim women in india to their male and female counterparts the study finds that muslim women have lower levels of education than muslim men and hindu women sahu examines the barriers to higher education faced by hindu and muslim young women in urban bengaluru the study finds that muslim young women in urban india are more literate than hindu young women but have lower levels of graduatelevel education then aheed notes that womens literacy rate in india is 628 and that muslims in india have one of the lowest literacy rates among religious groups overall the search results suggest that both hindu and muslim women in india have lower levels of education than men and other religious groups however there are some differences between the two groups with muslim women generally having higher levels of literacy but lower levels of graduatelevel education than hindu women the search results also highlight the need for continued efforts to promote education for all in india particularly for women and marginalized groups conclusion it is clear from the result obtained from the study of the data that the social status of hindu and muslim women there is a general level of attitude towards change women with higher education expressed less attitude and women with less education expressed more attitude education is the only influence which equally broadening the outlook of women towards social change therefore the need today is that education should be developed more and more the same fact has been accepted the intellectual development of a person as well as its attitudes beliefs interests etc and broaden its intelligence and thoughts this research would be much useful in future for study related to hindu and muslim women in different walks of life their attitude to educational economical religious and social behavior would be points of consideration in future there are wide possibilities of research study on the research problem and different researchers on the basis of their interest on their aspects of this useful and interesting problem research study can be done by selecting the present research would prove useful and purposive for researchers in times to come

education is an important factor in any society with the help of which both direction and condition of the society change in ancient india traditional education was imparted through religious institutions in the vedic period the status of women was very good and high women were able to work sidebyside with their husbands and could decide for their future life she had the right over the property of her father and husband swayamvar system was the strong foundation of the social status of women the study aims to find out the effect of revolution and progress in education due to social change in present times on hindu and muslim women in the study descriptive research design has been used it is clear from the result obtained from the study of the data that the social status of hindu and muslim women there is a general level of attitude towards change women with higher education expressed less attitude and women with less education expressed more attitude this research would be much useful in future for study related to hindu and muslim women in different walks of life

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leadership as a socially assigned and trusted role participants told stories of leadership as a role bestowed by community members and of how that role was respected by work colleagues outside the community they reported that the communitys perceptions about education level empowered a leader who could research and provide accurate advice and information education boosted participants selfconfidence as one described im not the expert but my level of education allows me to go seek the right level of education information that i can also spread being multilingual was advantageous in navigating and understanding media resources in english and other languages and it provided participants with additional leverage to inquire interpret and explain covid19 information mutual cultural understanding sharing common languages and connection with the community were described by participants as factors contributing to trust and connectivity one participant explained i share the same cultural background as community members like people from burundi and those that speak the languages i use … having supported different people and built trust from the community its from mutual understanding and the relationship that makes me play a key role being trusted by the community strengthened the participants confidence to be leaders one participant explained according to that trust i feel free to interact with people who ask to know something leadership as a continuous responsibility the responsibility of leadership was seen as continual one participant described leading the community in our regular gathering and another explained that we usually talk nearly every single day and pass what we have heard in the news in our local languages participants reported carrying various leadership responsibilities in ways that were caring and respectful this was displayed through words such as encourage help tell contribute share benefit and connect participants reported how they carried out their leadership responsibilities and mobilized to help comresearchers from the multicultural health and refugee health service conducted the interviews in english exploring participants roles in relation to covid19 information sharing community was defined as recently arrived refugee immigrants who identified as having democratic republic of the congo heritage living in the hunter new england region participants often chose to broaden this term to include refugees of central african background living locally leadership was ascertained by participants themselves all four participants selfreported being leaders in their community and this was corroborated by the other participants the congolese have a strong oral tradition that values storytelling as a way of making sense of the world and conveying knowledge 6 narrative analysis was employed to interpret the roles and experiences through stories 7 two researchers analysed the data individually before combining to create a paired analysis for each transcript researchers focused on the content of the stories and how the narrator organized information to convey meaning 8 similar concepts were grouped into categories forming two overarching themes results the participants comprised three women and one man aged between 20 and 60 years all could read write and speak both swahili and english and several minority languages three participants provided additional information reporting lived experiences as a refugee attainment of tertiary education and holding employment positions in australia that were external to their roles with the african community each participant shared stories using a similar structure where the main point was given first and then explained the participants circled back to their main points for emphasis and spoke confidently of community and culture the narrative structure and the content of the participants narratives revealed two aspects of leadership in this resettled congolese community that it is a socially assigned and trusted role and it carries an ongoing responsibility table 1 evidence supporting theme leadership as a socially assigned and trusted role leadership as a socially assigned and trusted role participants quotes role bestowed by others yeah the day i went to drop my cv and we talking and they say well we know you are a leader and this is the refugee from there and we know that you help them so we know you will help us as well and we work together importance of education and english language skills the educational background i have back home and here it added up to people to trust me people to ask me things … and also the capacity of advocating on their behalf to gain the trust in the community and also have something to contribute community members contact me because they believe as a leader that i have done more research … so they just want to double check because for some of them english language may still be low shared language and culture so its just mutual connection network onetoone talk that helps channel information and update one another so most times people would call and say we heard about this and ask how much more did you hear about this and then you have to go through it and explain in a language they understand because most of us we share … the same language and background so its an easy task to explain in their local language or in a language they understand better relationship with trust i strongly believe that my role as a community connector and also the trust the community has in me has impacted me to do everything that i can offer to the community responsibility as an ongoing phenomenon since i came i have good relationship with my congolese community and also african community around over 10 years to get to know each other and also to win trust from the community because we are here to help each other wherever help is needed when i can respond to i do thats how … even when an issue arises its easy to interact … the same way of sharing information about covid responsibility to act then we come out with the idea ok let us translate i did the translation in swahili then i post on my whatsapp then i say ok … just send me inbox and i will send you to read the safety … about what the meaning of covid what you must do how you going to wash your hands that stuff like that the basic stuff you see we have that burden of getting people to know what is happening especially about covid because there is also a lot of misinformation so when we get together or when we have the opportunity to meet with someone is trying to fix the information that they got that is not right responsibilty to share accurate information if we come across something that is related to covid before you send it out there you have to do a little bit of research so you check the correct source the government and if its something you heard from social media if you compare it to what the government has is the same thats when you get that and post it on the status or post it on the whatsapp so we need to ask questions and so we can have answers to those question and be confident with whatever we are saying responsibility to incorporate network and also the different work different jobs i do … all this gives me the position and strength to share what i have to contribute to building the community strength the leadership role entrusted to the participants also brought ongoing responsibility and accountability participants reported performing leadership roles by seeking out and conveying accurate covid19 information to the community in ways that were understood by the community similarly in the ebola response community engagement by health services that actively partnered with respected leaders and other community mobilizers was critical to success 10 during ebola outbreaks in central africa members of communities bordering other countries trusted local leaders not government health workers as a source of information about ebola similarly the congolese community in australia has strong trust in community leaders thus public health solutions should be tailored to communities by listening to and learning from community leaders 11 furthermore the ebola epidemic showed that a shift from the biomedical model for outbreak response towards a more holistic sociobehavioural model is necessary for policymakers to achieve collective cooperation 12 such frameworks have been recommended for the covid19 pandemic response worldwide 1012 the thoughtful engagement of congolese community leaders has also been described in management of sensitive issues such as sexual and reproductive health 13 community leaders in the democratic republic of the congo hold strong influence over the communitys perception of sexual health accessing of services stigma and cultural taboos 13 by engaging community leaders respectfully with twoway discussions leaders could become advocates for sensitive health issues within their community 13 respectful collaboration with community leaders allows public health messages to reach and be received by cald community members in a timely and meaningful way the world health organizations covid19 global risk communication and community engagement strategy notes that communitycentred participatory approaches provide opportunities for governments to support otherwise unreachable marginalized groups 1014 this is done by identifying and collaborating with community leaders to codesign and coordinate public health responses that are acceptable to the community 1012 munities for example by interpreting and translating key public health messages and pitching them in ways that were understood by community members one participant reflected most of us we share the same language and background so its an easy task to explain in their local language or in a language they understand participants described proactively using platforms familiar to community members for example participants called community members during lockdown periods translated and voicerecorded covid19 information and uploaded audiolinks to share on social media one participant explained that their response to act swiftly and dispel misinformation was in part because as a community leader my heart is to see people working within the regulation participants also took responsibility by passing on information to community members only after validating the information one participant explained i like my source to be accurate before spreading any information i need to check the government and health website that way i know lastly participants described how networking opportunities allowed covid19 information gained from their workplaces to benefit their community one participant described the strength of their network in this way my tentacles reaches sic everywhere so in terms of getting useful information it can come from anywhere discussion there is strong evidence supporting cald leader engagement in health care 12 but little is known about how community leadership is recognized and developed some insights have emerged from this work where participants have become community leaders through social processes and recognition commonality of culture and language were reported to be strong contributors to the communitys perception and trust of the participants as leaders during the covid19 pandemic in particular being strong english speakers afforded our participants opportunities to network across african and nonafrican spaces enhancing the flow of important public health messages as described by the united nations high commissioner for refugees higherlevel education turns students into leaders 9 the congolese community is diverse the stories and experiences of the four englishspeaking leaders interviewed may not represent other leaders in the hunter new england region and beyond particularly those with limited english ability the sociocultural context of communities may also impact the relationship between communities leaders and governments especially in settings of rapid change such as this pandemic hence governments need to be flexible and engaged the lead mhrhs researchers are themselves of a cald background therefore particular stories and focus may have been drawn from the participants bringing strength and opportunities for deeper conversation the small number in this study suited the approach of narrative analysis exploring the contextual stories and opinions of participants interviewed but is a limitation the covid19 pandemic has precipitated responses from community leaders to fill a void in public health communication messaging the congolese community in this study had access to people who were socially assigned and given responsibilities as leaders these individuals were educated and multilingual and had collaborative abilities and common cultural experiences by nurturing twoway communication government health services can learn and improve upon current methods of covid19 messaging to reach cald communities to further reduce risks to communities the public health response in a pandemic should be underpinned by partnerships with leaders to reach common goals further studies on leadership and engagement with cald communities are essential ethics statement this study received approval from the hunter new england human research ethics committee conflicts of interest the authors are salaried employees of hunter new england health under the new south wales ministry of health

n australia collaboration with leaders of culturally and linguistically diverse cald communities has been recommended for communication of coronavirus disease 2019 covid19 health information particularly around vaccination 12 many refugee communities are tightly knit and rely on advice and guidance from community leaders 3 congolese immigrants are a newly emerging population in regions of australia such as the hunter new england area with most coming to australia as humanitarian arrivals refugees from the democratic republic of the congo have been subject to human rights violations related to the countrys history of intermittent armed conflict and political unrest 45 most refugees from the democratic republic of the congo crossing the border reach rural settlements or camps in neighbouring burundi rwanda tanzania and uganda where work and educational opportunities are limited 5 additionally basic humanitarian needs have been further compromised by multiple ebola virus disease outbreaks since 2018 4 many congolese are multilingual but it is estimated that less than 50 of congolese refugees speak english and only 10 report the ability to read and write english well 5 by listening to community leaders we explored and gained insights into the concept of leadership among a newly emerging congolese population in australia and how leadership is being enacted during the covid19 response no similar work has been reported in australia or internationallyfour participants of congolese or burundian background were recruited by purposive sampling among community leaders after initial recommendation by a local refugee health nurse the participants took part in semistructured interviews as part of a larger project three participants were interviewed together and one individually

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introduction correctional facilities have been identified by the center for disease control and prevention as key settings for improving hiv prevention efforts because hiv affects a disproportionate number of incarcerated persons 1 prevalence estimates indicate that 14 of all hivinfected persons in the us may be released from a prison or jail in a 1year period 2 and aids case rates are 35 times higher in the us prison population than in the general population 34 twothirds of hivpositive incarcerated persons are diagnosed and begin treatment for the first time during incarceration and many return to the community within 2 years 5 6 7 8 9 periods of incarceration and community reentry can provide a window of opportunity for reducing hiv transmission risk behaviors postrelease is a time of high risk behavior for many formerly incarcerated people including those who are hivpositive 10 11 12 13 multiple factors have been linked to increased postrelease transmission risk behavior among hivpositive persons 14 while behavioral intentions to practice safer sexual and drug use behaviors upon release may be high among hivpositive men and women in prison these intentions are often quite difficult to realize 13 upon reentry to the community subsistence needs such as housing money medical benefits and jobs are frequently viewed by formerly incarcerated hiv positive persons as much higher priorities than hiv risk reduction strategies 15 it is therefore important to identify and address potential barriers to hiv prevention that may occur inside and outside of prison and to develop prevention services that will meet the longterm needs of hivpositive persons transitioning from prison to community settings 16 17 18 19 20 research suggests that engaging hivpositive persons both prior to prison release and immediately following prison release is likely to positively impact health behaviors including substance use and sexual behaviors 1121 however even intensive case management may not sufficiently reduce postrelease risk behaviors 1122 more effective programs to help formerly incarcerated hivpositive persons reduce risk behavior have been called for 781213162324 but intervention research with this population is largely in the formative stage 1121 for example interviews with communitybased and correctional treatment providers suggest that prevention interventions delivered during the prisoncommunity transition need to be brief engaging and tailored to varying levels of knowledge education and risk behavior experiences 21 interviews with formerly incarcerated injection drug users suggest that interventions for this target population should aim to improve motivation for safer behavior increase condom negotiation skills and address stigmarelated barriers to utilizing needle exchange programs 21 a seminal review of randomized controlled trials targeting sexual risk reduction in hivpositive persons included 15 trials conducted in community or clinical care settings 25 metaanalysis of these trial findings showed interventions that included information motivation and behavioral skills components increased condom use compared with interventions that had only one or none of these components interventions that did not include any of these components had nonsignificant effects on condom use 25 these conclusions were consistent with other metaanalysis findings that characteristics of successful preventions interventions include being based on behavioral theory specifically designed to change hiv risk behaviors and providing skills building 26 the informationmotivationbehavioral skills model for hiv prevention 27 has been successfully applied to reduce transmission risk in several hivpositive populations 28 29 30 the imb model posits that hiv preventionrelated information and motivation work primarily through hiv preventionrelated behavioral skills to affect the initiation and maintenance of safer sexual and substance use behavior 27 direct effects of motivation and information on safer behaviors are more likely for less complex prevention behaviors 27 accordingly effective hiv transmission risk reduction interventions should aim to correct deficits and build on strengths in risk reduction information motivation and behavioral skills 27 elicitation research is strongly recommended prior to implementation of populationtailored interventions to identify specific strengths and deficits in preventionrelated information motivation and behavioral skills domains that can inform targeted intervention content for various subpopulations 3132 in this paper we describe elicitation interview findings regarding hiv preventionrelated strengths and deficits in each of the imb model domains among a sample of hivpositive men and women awaiting release from a state prison system our formative qualitative research is meant to provide useful contextual information for guiding culturally appropriate prevention intervention work with this understudied hivpositive population methods research setting inperson recruitment occurred in 20082009 at the university of wisconsin medical center in madison wisconsin where hivpositive persons incarcerated in wisconsin state correctional institutions receive centralized medical services a research nurse consented participants and then scheduled telephone assessments with them in coordination with prison health unit nursing staff already aware of patients hiv status to maximize privacy participants received study calls on health unit telephones in 15 state prisons located throughout wisconsin calls were not monitored by security personnel and correctional officers or other inmates were not present in the interview room for many participants nurses were able to leave the interview room after calls were initiated but for security reasons nurses sometimes remained in the interview room in this prison system education about the transmission of sexually transmitted diseases including hiv is typically offered as one component of broader health education classes which persons who are hiv negative or positive attend together there are no formal classes specifically offered for hivpositive inmates incarcerated hiv patients may discuss hiv transmission with physicians on an ad hoc basis but no formal prevention counseling program is routinely offered to them at the university clinic participant consent and recruitment thirtyone potential participants were informed by a research nurse of the opportunity to participate the nature of the study was explained in private exam rooms at the university medical center the wisconsin department of corrections group health and university of wisconsin institutional review boards approved consent and recruitment procedures potential participants were informed that the study had received a federal certificate of confidentiality to protect their privacy and that any questions about specific sexual and drug use behaviors would focus on activities in the community rather than in prison of the people approached thirty gave written consent to participate in the study and one woman declined to participate the final sample falls within the recommended parameters for elicitation research sample size 33 participant selection inclusion criteria for the sample pool included being 18 years or older hivpositive incarcerated in a wisconsin doc facility with a documented mandatory release date and able to verbally communicate in english exclusion criteria included documented diagnosis of dementia or other severe cognitive impairment that would preclude informed consent purposive sampling strategies were used to select 30 hivpositive incarcerated individuals with varied demographic characteristics incarceration histories and hiv disease and treatment characteristics selection criteria were identified from clinic records and brief inperson screening interviews at the time of recruitment in qualitative research it is meaningful to elicit responses from individuals who may have different perspectives and experiences without seeking to select all possible combinations of such participant characteristics table 1 shows the characteristics of the sample assessment interview we conducted one 3040 min telephone interview with each participant all interviews were digitally recorded as an incentive for completing the interview a 10 money order was deposited in participants prison canteen accounts interviewers used a structured interview guide based on the domains of the informationmotivationbehavioral skills model as applied to prevention for positives 2930 openended questions were asked for each of the domains listed in table 2 analysis of qualitative data qsr nvivo software was used for data management and analyses digital recordings of interviews were transcribed verbatim to ensure accuracy interviewers compared the transcripts to the original recordings and corrected discrepancies they recorded field observation notes regarding interview processes in association with each interview and expanded upon these notes immediately following the session 34 data were analyzed using adapted grounded theory strategies 35 to identify themes relevant to core elements of the imb model and the hierarchical associations between these themes the investigative team discussed new categories and themes that did not appear to fit into the conceptual framework and made modifications accordingly when suggested by associations overlap or diversions in the data thematic categories were refined merged or subdivided relations and associations among categories were interpreted and decision trails documented 3637 this process continued iteratively until thematic saturation was achieved a codebook was developed to include themes illustrative texts and node addresses two members of the analytic team formally content coded all transcripts they discussed and resolved initial interrater discrepancies with a third coder until consensus was obtained overall interrater agreement between the two coders was 93 results main themes that emerged from analysis of elicitation interview data are summarized in table 2 information participants were asked to discuss the information sources and needs of hivpositive incarcerated people they also responded to questions about their own knowledge related to hiv transmission information needs information needs for recently diagnosed incarcerated persons being diagnosed with hiv in prison was considered particularly problematic by participants a lack of social and emotional support in prison was seen as delaying the emotional processing needed to formulate questions or seek information maybe some oneonone because i havent really talked to anybody except for the people at university hiv clinic the people in this prison facility dont address my issues i mean so basically i really havent even dealt with what has happened you know that i found out that im hiv positive maybe a social worker or a counselor thats trained to help people with this kind of you know because i really dont even know anything about it i know about the t cells and i know that its transmitted through blood and needles basically sex you know is it i dont even know is it transmittable through semen whether diagnosed in prison or in the community emotional distress or denial reportedly prevented many from seeking prevention information at first then initial questions often focused on transmission risks from casual contact and how participants contracted the illness a few who had a partner at the time of diagnosis sought information about safer sex practices with serodiscordant and seroconcordant partners only one person mentioned seeking risk information around drug use information needs for incarcerated persons who were not recently diagnosed over time respondents reported beginning to ask more specific sexual and drug risk reduction questions well i imagine they would want to know is there any way they could really have sex without spreading the virus from the understanding that ive had you must wear a condom each and every time you have sex for the rest of your life now since you have hiv not to spread it to others thats something that kind of troubles me some who had lived with hiv relatively longer felt their knowledge was fairly complete i relied on the information that was available to me you know that if im going to have sex or protected sex and stuff like that i came to grips with my hiv pretty pretty soon after i was you know it was within months you know i mean i was over the anger and denial stage and the acceptance stage pretty quick sources of preventionrelated information in prisonseveral participants said they received little or no preventionrelated information while incarcerated and the few that did receive it reported finding hiv information mainly through written media available in either the prison health services unit or through the library a few mentioned accessing videos but they considered these outdated a few of the women referenced support groups none of the men did the prison health services unit was cited most often as the best information source though the university hiv clinic was also mentioned only a few participants referred to getting information from another person who was incarcerated or an outsider internet access is unavailable or heavily restricted and was not viewed as a main source of information while incarcerated unmet informational needsalthough almost half of participants spontaneously raised at least one transmissionrelated question during the interview none were specific to injection drug use while all participants knew basic information such as that condoms can prevent transmission they often sought some way of quantifying risk eg how much condom use or an undetectable viral load decreased risk and how risky oral sex or kissing were they also asked questions about safely having children when one has hiv and the risk of seropositive sex some expressed confusion about appropriate barrier use when performing oral sex on a female partner others had questions about legal penalties for exposing others to hiv i guess it was too late when the questions did come up because i had got in trouble for criminal transmission i never knew if there was an actual statute a surprisingly high proportion of the sample had questions or voiced concerns about casual transmission involving nonsexual saliva urine or blood exposure so i play a lot of basketball so i wanted to know like you know how if i got cut and somebody else was cut or something like that or scratched or whatever it was common for participants to indicate early in the interview that they were well informed about hiv prevention and then for preventionrelated informational needs to emerge spontaneously later in the discussion transmission risk knowledge by partner serostatuswhen asked about the risks of unprotected sex with someone who was hivnegative the most frequent responses were hiv exposuretransmission and exposure to other infections specified as stds hepatitis or fungal or yeast infections most often they brought up the risk of other infections as an afterthought and described it as much less significant than the potential for infecting someone else with hiv one mentioned that having hiv makes one more susceptible to contracting other stds while another said contracting an std makes hiv 10 times worse several respondents stated they didnt know the risks of serodiscordant sex believed they were minimal or thought they could be minimized through strategies such as choosing particular roles or pulling out prior to ejaculating only one person mentioned hiv transmission as a risk connected with serodiscordant needle sharing even though a third of participants reported iv drug use other infections were the most common risk mentioned in the context of needle sharing some did not know if there was risk or gave a confused response and one believed there was little or no risk in needle sharing when questioned about the risks of two hivpositive people having unprotected sex most participants expressed some awareness that this was not recommended the specifics of superinfection were less well understood there were references to different strands viruses stages or stems reinfection mutant copies causing viral load to go down messing with your immune system viruses that counteract each other two strains making a stronger one etc only two respondents mentioned possible resistance to medications associated with this issue some did not know if seroconcordant unprotected sex carried risk and some thought there was no risk involved i guess if you guys levels are the same then its really not going to be a problem in fact i would prefer to be with somebody that had it only a few mentioned the risk of contracting other infections and these included colds and pneumonia questions about seroconcordant needle sharing elicited similar references to superinfection however the most common responses were dont know or unsure some of those mentioning superinfection also referred to the risk of other infections such as hepatitis and mrsa others thought there was risk but could not specify what risk probability knowledge undetectable viral load when asked about the risk of transmitting hiv when viral load is undetectable nearly half simply stated that there was still risk in this circumstance several either did not know or were unsure among these one person did not know the term undetectable and another thought that transmission was still possible but a weaker strain would be transmitted a few thought there was less risk of transmission effect of antiretroviral treatment on transmission as with an undetectable viral load most participants did not understand the potential decrease in transmission that accompanies effective antiretroviral treatment nearly half stated that hiv transmission was unaffected by art treatment what ive heard is that medications protect me from the virusyeah it does nothing as far as protecting you from passing it several either did not know or were unsure of the effect on transmission while one person felt the risk would be increased since effective art makes having hiv seem less threatening some stated the transmission risk would be decreased one person had heard this but did not believe it because he felt that knowledge about hiv changes frequently risk assessment heuristicswhen asked how they decide whether someone else has hiv most commented that although one cannot tell based on appearances others make these types of judgments routinely several felt the only ways to know were to ask or for partners to disclose their status directly a few believed testing was necessary a few made comments about heuristics for deciding partner status such as assuming that the other person is hivnegative unless told otherwise and that attractive people are hivnegative regarding heuristics used to determine hiv status of drug sharing partners the most common statement was that one cannot tell without direct disclosure one individual added that if someone is sharing needles that person is assumed to be positive another commented that seeing a former needle sharer initiating safer behavior would lead to a belief that the person had become infected a few stated that one could tell based on appearance motivation respondents discussed their personal motivation and intentions to avoid spreading hiv through sexual and druguse behaviors on release and their perceptions about social norms for risk behavior and social support for safer behavior personal and social motivation for safer behavior personal motivation the most frequentlymentioned personal motivational barrier to engaging in safer sexual activities was a strong focus on and desire to have sex after release yeah theyve been waiting i mean its like a little bomb waiting to go off other prominent factors related to personal motivation for risk reduction included denial to oneself about having hiv and alcohol or drug use affecting judgment about needle sharing or sexual activity a lot of the women in herethey say oh you know i cant wait to get out and go to the bar and get drunk and i cant wait to go to the hood and get my crack well youre probably going to get really drunk and the chances of you protecting yourself are probably slim to none avoiding alcohol and drug use was generally viewed as necessary both for taking care of oneself and for maintaining reduced risk behavior following community reentry a few participants commented that anticipation of a drug high can override intentions to reduce risk when a clean needle is not available a main personal motivational barrier described as related to both safer sexual and drug use practices was depression a feeling that im going to die anyway or not caring about oneself or others negative emotional states were the most frequent reasons mentioned for not using condoms anger and depression were viewed as likely emotional responses to readjusting to the community or to hiv diagnosis that could reduce the perceived importance of using condoms either due to not caring or desires to get even other personal motivational barriers specific to using condoms were dislike of how condoms feel or look fear of erectile dysfunction with condom use and disruptions to the heat of the moment conversely personal legal consequences were described as a motivating factor for condom use wisconsin states policy of prosecuting individuals for not disclosing status during consensual sex and imposing severe penalties appeared well known by those with hiv in the correctional system other personal motivators for condom use included wanting to do the right thing and protecting oneself social motivation beliefs regarding more social aspects of risk and safer behaviors also emerged as important influencers of motivation some potential sexual partners were expected to demonstrate a welcoming attitude toward newly released individuals because those leaving prison are perceived as free of stds and have not had sex for a long time which contributes to their attractiveness i guess you glow when you get out of prison or something like that that you have kind of a glow to you and women pick up on that and then especially when you tell them well i havent had sex in 10 years other social motivational barriers included peoples fear of disclosing their status to partners partners lack of honesty about hiv status or whether they had had other partners during the incarceration lack of attention to hiv status on the part of parole officers social workers and others availability of people who offer money andor alcohol or drugs for sex frustration caused by restrictions on the activities of sex offenders and friends planning to celebrate their release with high risk activities social factors specifically mentioned as influencing condom nonuse included having an hivpositive partner manipulation or coercion by a partner reluctant to use a condom and the concern that using a condom would make their partner suspicious especially if hiv status had not yet been disclosed some participants talked about the potential effects of being in lovean uninfected partner might be motivated to become infected to show a strong bond with the infected partner if the other person was like i dont care i love you ill lets be infected together which is idiotic but you know i can see that happening reports of negative reactions to condom use occurred for casual partners and steady partners most respondents said that if a casual partner refused to use a condom they would not have sex with them stopping the spread of hiv was the foremost reason for condom use framed as a moral decision or a result of empathy or caring for others several also mentioned preventing transmission of other infections having a steady partner supportive of condom use was also viewed as an important social motivator the largest number said their steady partner didnt mind with a few indicating their steady partner did not like using condoms but would go along with it a few reported strong partner commitment to safer sex other social factors viewed as increasing the likelihood of safer sexual behaviors included support groups and probation restrictions on activities such as associating with other felons or using the internet community social norms for condom use when asked what important others think about condom use a majority reported positive attitudes among family members my grandmother she thinks i need to just you know stay with the person im with and that we need to be safe secure and do whats best for me and my health and that persons health some participants reported encouraging or pushing others to use condoms including their children and a few said that family members had become more motivated to use condoms after their diagnosis others mentioned the fact that condom use is expected especially among women many also described community attitudes or behaviors that discouraged condom use the most frequently mentioned one being that friends and family members simply did not talk about sex or condom use a smaller number described friends and family who were perceived as leading highrisk lives and not caring about condoms some stated that other people do not really care about spreading hiv or feel that hiv is not an issue others described some hivpositive individuals as angry and hurt not caring to whom they spread it behavioral intentions and partner statuswhen asked about intentions to have sexual relationships with partners who are hiv negative or whose status is unknown participants responses were mixed some said they would others would not and some planned to have sex only with their current partner a few were unsure or not ready to deal with sexual relationships i think im going to be a little bit nervous when i get out im kind of dreading the dating game so to speak when i get out its kind of like well hi im hiv positive im a threetime felon would you like to get to know me thats you know what do you really say when asked whether partner hiv status would affect condom use some responded that it would noting that if one partner were known to be positive and one negative the couple would be more likely to use condoms because it takes the guesswork out of it you wouldnt pick up a gun if you knew it had a hair trigger on itif somebody knew that they were positive they would demand the condom use and demand you know they would be more safe with the other person postrelease behavioral intentionsmany participants reported intentions to protect others from transmission of hiv spontaneous mentions of safer drug use intent were less frequent than expressions of sexual risk reduction intent even by former drug users some who had injected drugs in the past said they planned not to return to injecting drugs or using other substances none of the participants stated that they personally intended to use needle exchange programs when they returned to community either because they expected not to resume injection drug use or due to perceived access barriers regarding safer sexual practices not specific to condoms a few participants mentioned intentions to develop a longterm relationship or to avoid sex others expressed their resolve to disclose hiv status to sexual partners a wide variety of intentions for condom use or nonuse are described below condom use intentions most participants expressed intentions upon release to use condoms always or in every situation when asked about specific sexual acts several said they would use condoms during oral sex or intercourse a few said they would use condoms despite a partners objection regardless of their partners hiv status during mutual masturbation if they had sex outside their main relationship or even when drinking one man said he began to use condoms in a moment of spiritual insight in which he decided it was wrong not to care if he infected others i really had this mindset of i dont really care and fuck it let me get however many how i got it and you know and i just said no i cant think like that because im a im a very churchgoing person noncondom use intentions asked about situations in which they would not use condoms some said they would not use them for nonintercourse sex when they were performing oral sex on a woman or if the relationship was committed or serious a few said they would not use them if their partner was also hivpositive specifying that in this case they would both need to be tested for stds and our levels have to be the same a few said they would not wear condoms if using drugs or alcohol with their main partner or if they and their partner decided not to sexual abstinence intentions a minority of participants stated a desire or intention to abstain from sex with others for at least a period of time after release some believed they would remain abstinent for the rest of their lives others thought they would wait to have a sexual relationship a few seemed ambivalent one stated a desire to be abstinent and almost immediately contradicted himself the most frequentlymentioned reasons to remain abstinent were a desire to prevent the spread of hiv to others and a feeling that sex was not as important as it was previously after awhile or if we was getting really really close and i had broke it off i didnt even want to get into iti dont trust condoms you know so i really i um i would rather just not do it period because i would hate to pass this on to somebody like somebody passed it onto me and to me i might as well be locked up if i do something like that because im giving somebody a death notice and thats just as bad as murder to me motivation towards disclosuremany participants offered reasons both for and against disclosing their hiv status indicating ambivalence the strongest facilitator of disclosing hiv status to others was timing particularly telling partners before sexual involvement started selfacceptance and feeling accepted by others were also important yeah once you accept it for yourself then its easier to tell other people and either i mean accept how theyre going to react good or bad because if youre not at peace with it then youve just increased the likelihood that theyre not going to be some referred to incarcerated persons having papers or documents with their std test reports on them when released which a few noted could be shown to potential partners or possibly altered several talked about trust in and support from others some brought up legal penalties for not disclosing and some were motivated by a desire to help and protect others most perceived fear of rejection as the biggest deterrent to disclosing hiv status several lacked trust that their confidentiality would be respected some expected that their sexual partner would respond with feareither of becoming infected or of what would happen to the hivpositive person in the future some feared or had experienced prior hivrelated stigma or rejection after disclosure others feared a violent reaction by a partner or by fellow inmates if their status became known in prison some anticipated feeling shame despite these fears most thought that disclosure was important in at least one of a variety of situations including sexual encounters interactions with close family members and any situation in which someone might be accidentally exposed a few thought that people should always reveal their status to sexual partners behavioral skills participants discussed their perspectives on what would help or hinder hiv risk reduction behaviors upon release from prison because of irb restrictions on asking incarcerated people specific questions about their current highrisk behaviors in prison behavioral skills questions had to be worded indirectly and oriented towards future behaviors in the community thus responses often expressed motivation intent or opinions about others behaviors behavioral skills impacting condom use on releaseaccess or having condoms on hand was considered important immediately upon release from prison structural suggestions for ensuring access after release included handing them to people as they walk out the prison gate having them available at needle exchanges planned parenthood local aids service organizations or medical clinics or having people hand them out on the street other respondents felt it was up to the individual my first stop is going to be the clinic so i can get me a bag of them rubbers a few people did not think any assistance was necessary because condoms are already so accessible participants mentioned that condom use might be improved by attending group meetings focused on skills building before leaving prison use of ultra sensitive condoms to surmount objections to how they feel having the right size condom and avoidance of alcohol and drugs conversely participants considered lack of skills and resources for accessing condoms to be a barrier to use when transitioning back to the community like many other aspects of this transition access to condoms was hindered by lack of money in here if you come in with nothing you stay here with nothing you leave with nothing what are you going to do hit the drug store when you get out of here with nothing discussing condom use with a partnermany respondents said that it would be quite difficult to initiate condom use with a regular partner with whom condoms had not been used in the past this issue was especially significant for individuals who had been diagnosed with hiv in prison and were subsequently returning to the community nearly half thought a partner would be fearful or suspicious if condom use was suggested because of concerns over infidelity or having something there might be a question why you know why do we got to wear a condom now after you know you might have had sex multiple times that would be like really bad other participants felt their partners would object to condom use because of loss of sensation or closeness several participants stated that it would not be difficult to tell a partner they wanted to use a condom perceived community awareness of hivstd issues was believed by some to aid discussion or use of condoms others felt that it would be easy to give reasons other than their hiv status for condom use such as pregnancy prevention nonspecific concerns about safety or protection or the recently released persons suspicions about hisher partners sexual activities in the community while the partner was incarcerated skills thought to be important for introducing condom use into relationships included educating partners about hiv transmission disclosing ones hiv status making condom use fun and discussing how to enhance pleasure despite their use or talking about condoms before touching begins some respondents did not feel condom use was subject to discussion they felt that presenting one or putting one on spoke for itself needle sharinguse of needle exchange programs was the most frequently mentioned skill for injection risk reduction particularly in reference to ones own past behavior or others future behavior one person added that syringes with retractable needles should be provided while another suggested that hiv clinics should incorporate needle exchange into their services other skills noted included always having ones own needle on ones person avoiding needle reuse and avoiding sharing ones needles with others i never used the same water or the same syringe as somebody else you know i used my own cotton and my own everything and i wouldnt let anybody share with me while some participants considered needle exchange programs helpful a few mentioned them as presently insufficient either because they do not supply adequate information or because there are not enough programs one person commented that clean needles are not affordable or legal another stated that cleaning needles with bleach was ineffective and that a belief in the effectiveness of this technique hindered safer behavior other behavioral strategieshiv education was the most frequently mentioned way to encourage individuals leaving prison to reduce risk behaviors risk reduction strategies that were viewed as effective included having a plan being ready to repel advances limiting the number of sexual partners and avoiding hustling a few individuals endorsed lowering sexual risk and taking responsibility for ones own protection by not believing what others say about their std status one person mentioned the importance of seeking support to avoid feeling lonely or isolated which could trigger risky behavior a few cited abstinence as a prevention strategy and encouraged masturbation and the use of sex toys and pornography to maintain it finally using other protection such as foam was mentioned as a strategy to reduce transmission strategies outside of sex and drug use behaviors included handwashing and exercising care with injuries or exposure to bodily fluids a few participants mentioned nondisclosure of hiv status to a sexual partner as an ineffective behavioral strategy in addition disclosure could be ineffective if the partner did not believe it or did not care some criticized not ejaculating as ineffective prevention along with paying for sex having sex in prison and having multiple partners one felt that abstinence would not work because it was too hard to maintain privacy and safety issues the prison context in which safety through concealment of hiv status was often mentioned as critical flavored the discussions about core imb constructs and affected the interrelationships between information motivation and behavioral skills of particular importance participants consistently made reference to the interaction between their attempts to implement basic information seeking skills and their beliefs about the very high costs of doing sopotential hiv status disclosure some participants noted the difficulty of discerning whom to trust about hiv health issues while incarcerated this exacerbates social isolation and may be a barrier to information seeking even when participants in prison reported suspecting that another person was hivpositive or having experiences that only another person with hiv would have they said they were reluctant to disclose their own status because of fear that the information would be shared with others several participants also indicated difficulty finding a private time and place in the prison setting to read sensitive materials related to hiv this was viewed by participants as an important environmental issue because of stigma and safety concerns the lack of privacy while incarcerated was seen as increasing the risk that other people in prison might learn and disclose ones hiv status to others potentially leading to social ostracism or physical harm some participants specifically noted they do not feel it is safe to have written information about hiv or medical papers in their possession giving them reading material and stuff because of the privacy issue is not i mean i hate to say it but then you start putting them in danger for just having the material discussion information motivation and behavioral skills domains provide an appropriate framework for many of the hiv prevention barriers that are experienced by incarcerated hivpositive persons consistent with prior prevention research conducted with hivpositive persons in the community 263038 interviews with this incarcerated sample suggest that interventions directed at hivpositive persons should have certain characteristics to be most effective they should provide information about how viral load impacts transmission risk in addition to general information about transmission routes should focus efforts to increase motivation on protection of others as well as on selfprotection and should attempt to enhance behavioral skills specific to hivpositive persons in addition to general prevention skills research in community and primary care samples 2631 indicates that population targeted and prevention focused interventions may be better able to address the specific transmission prevention deficits of hivpositive persons these recommendations for designing effective prevention interventions are in direct contrast to the nontargeted non hivspecific educational programs available to hivpositive persons incarcerated in the wisconsin state correctional system our findings point to missed opportunities for education and counseling during incarceration and indicate that resources should be allocated to the program development and evaluation of prisonbased interventions that are tailored to hivpositives structural barriers to hiv education in prison were not as explicitly captured by the imb model as were social barriers a number of incarcerated hivpositive people expressed confidentiality and safety concerns that could interfere with delivering hiv preventionrelated information in a prison setting interview questions aimed at eliciting knowledge about transmission risk among hivpositive persons awaiting release from prison revealed a lack of understanding about specific transmission information that appeared partially due to barriers in accessing hiv information while in prison the incarcerated individuals we interviewed perceived that they were cut off from private immediate and updated hiv prevention information resources like the internet street campaigns and various forms of public media therefore it may be helpful for prisonbased interventions to provide updated information through alternative means that are sensitive to their concerns about hiv status being discovered by correctional officers or other incarcerated persons such means include providing information to all inmates regardless of status and proactively including hiv prevention services as an integrated part of routine hiv medical care services provided to prisoners one study conducted with incarcerated men found that hiv knowledge was comparable to that reported in a large health survey in the community 39 one would hope that hivpositive inmates might have fewer information deficits regarding hiv transmission than prison populations in general however despite the generally good basic transmission knowledge we observed 40 of our sample had questions or concerns about transmission risk through casual contact this finding was quite consistent with prior studies conducted with general prison populations that described moderate to high levels of hiv knowledge among prisoners with the most notable deficits involving knowledge about casual contact 4041 given the heightened degree of stigma among both incarcerated individuals and prison staff that has been shown to permeate correctional settings 42 and the secrecy that results from fear of persecution for being discovered to be hivpositive emotional processing of the diagnosis may be more difficult for incarcerated people who learn about their diagnosis while in prison efforts to provide a safe way to discuss their illness beyond the posttest counseling that is traditionally provided in testing scenarios may be necessary providing proactive emotional support and opportunities to discuss reactions to diagnosis within a safe and confidential venue may help alleviate distress and allow for incarcerated individuals to more quickly ask questions and address concerns about their own infection this could increase capacity and motivation to learn how to reduce transmission to others the process of community reentry is challenging for all incarcerated people 43 for those living with hiv the challenges may impede engaging in secondary hiv prevention many hivpositive participants stated that sexual contact and substance use were likely to occur at a more frequent rate and in a less cautious manner immediately following incarceration without prerelease interventionparticularly for those diagnosed in prisonmany will likely return to their communities without ever having engaged in skillful discussions about condom negotiation or hiv disclosure in addition to skills training to acquire free condoms in the community one obvious structural intervention that seemed widely supported by participants was provision of condoms as people are released from prison another potential way to reduce risk during reentry would be to support releasees in obtaining the skills necessary to disclose their disease status to family and friends who may otherwise encourage highrisk behavior transmission risk during community reentry can also be impacted by the psychological stress frustration or hopelessness that many newly released individuals may experience when their initial optimism and excitement about regaining freedom fades in the face of common adjustment problems these can include finding employment and housing experiencing barriers to financial support as an exconvict fearing consequences for lack of compliance with parole officers staying on lifesaving antiretroviral medications without the health care provided through the prison system and negotiating the dynamics of parenting and intimate relationships after the separation of prison time 43 psychological distress and psychiatric disorders are reported at alarmingly high rates among prison populations 44 and many do not receive treatment for their distress 45 the negative affective states described by study participants if left unaddressed at prison release could result in high hiv risk related to substance use consequently prison to community transition interventions seeking to reduce sexual and drugrelated risk behaviors should provide alternative stress coping strategies ahead of time and supportive case management and assessment of psychological distress following release while many incarcerated participants reported being highly motivated to reduce the risk of hiv transmission to others when they reenter the community a few were not as strongly motivated by a desire to protect others and some voiced perceptions that other hivpositive persons lack sufficient concern about risk to others attribution of responsibility or blame for ones hiv status to others has been shown to predict high risk sexual behavior with those who believe someone intentionally infected them found most likely to engage in risky sex 50 given potential differences in empathy and personal responsibility among participants and others in their community prevention interventions for incarcerated or formerly incarcerated hivpositive people should tailor motivational messages based on these observed strengths and deficits in preventionrelated social motivation that is it may be beneficial to tailor motivational messages to individuals capacity for empathy as well as to the presence or absence of perceived community norms supporting safer behavior study findings should be viewed in the context of restrictions on the interview content that could be explored in interviews with currently incarcerated persons some participants may not have felt comfortable discussing attitudes or behavioral intentions they believed might be viewed as socially undesirable immoral or legally questionable for example such discomfort may have led to overstated sexual or substance use abstinence intentions because stated abstinence intentions appeared to be associated with resistance to planning for future risky situations interventions that begin during incarceration will need to address this potential barrier to behavioral skills training likewise due to concerns about selfpresentation some incarcerated participants appeared reluctant to admit any lack of preventionrelated knowledge despite observed information deficits thus interventions with this population must be tailored to address not only a wide range of actual preventionrelated knowledge 21 but also different levels of perceived or acknowledged knowledge deficits another potential limitation involved our assessment of community preventionrelated behavioral skills while participants were still incarcerated while this approach likely enabled us to include high risk persons in this elicitation research who might be difficult to reach after release it also likely elicited descriptions of future intentions and past behavioral skills more than current risk reduction skills however findings from this study appear consistent with past research that surveyed hivpersons preand postrelease 13 great variability in hiv preventionrelated strengths and deficits was observed among incarcerated men and women in this study a number of potential moderators of the relation between imb constructs and safer behavior were also identified including individual mental health and substance use characteristics as well as environmental barriers to prevention commonly encountered during and after incarceration these formative research findings suggest that interventions for hivpositive persons transitioning from prison to community settings should be designed to mitigate prisonrelated prevention barriers experienced by this population as well to allow for individual level tailoring of information motivation and behavioral skills intervention content main themes by preventionrelated imb domains preventionrelated imb domains main themes sources of information and information seeking • confidentiality concerns sharply limited information seeking and access during incarceration • at initial hiv diagnosis information needs focused on emotional coping transmission risk of casual contact and how or from whom they contracted it specific questions about transmission tended to arise later • information was mainly accessed through written media no prison groups or programs existed specifically for those with hiv and computer access was very restricted transmission risk knowledge • when asked most people denied having transmission related questions however such questions tended to arise spontaneously during interviews • there were far more questions related to sexual transmission than to injection drug use despite the fact that onethird of participants had used injection drugs • motivators for risk behaviors included fear of status disclosure being in love and partying with friends or family to celebrate release some potential sex partners considered those recently released to be clean desirable partners initiating condom use when not previously used was considered difficult • motivators for risk reduction included altruism supportive partners and changing norms endorsing condom use in the community restrictions on activities during probation decreased opportunities for risk behavior risk reduction strategies • access to condoms was critical but problematic for financial and logistics reasons immediately upon release from prison • external supports and environmental factors were considered important in avoiding substance use or in using drugs more safely needle exchange programs were viewed as the strongest facilitator for injection drug risk reduction • opinions about the effectiveness of educational programs and materials in reducing hiv transmission risk were mixed • effective ways to communicate to a partner about condom use included simply presenting one discussing it before touching disclosing status and giving reasons other than hiv status for their use selfefficacy • participants felt it would be particularly difficult to initiate condom use on release with a partner with whom condoms had not been used in the past • a high level of abstinence selfefficacy for sex or substance use was a potential barrier to contingency planning • another barrier to risk reduction behavior on release was a fear that others would regard these behaviors with suspicion other • lack of privacy and not knowing whom to trust in prison were barriers to seeking hivrelated information and social support preventionrelated imb domains main themes • hiv disclosure concerns included fears about social stigma ostracism and threats to personal safety

greater understanding of barriers to risk reduction among incarcerated hiv persons reentering the community is needed to inform culturally tailored interventions this qualitative study elicited hiv preventionrelated information motivation and behavioral skills imb needs of 30 incarcerated hiv men and women awaiting release from state prison unmet information needs included risk questions about viral loads positive sexual partners and transmission through casual contact social motivational barriers to risk reduction included partner perceptions that prison release increases sexual desirability partners negative condom attitudes and hiv disclosurerelated fears of rejection personal motivational barriers included depression and strong desires for

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diabetes technology and therapeutics evaluating the performance of the indian diabetes risk score in different ethnic groups this paper has been peerreviewed and accepted for publication but has yet to undergo copyediting and proof correction the final published version may differ from this proof to help in early diagnosis management and optimal control of diabetes mainly in mass screening programmes in india and america downloaded by university college london from at 122719 for personal use only introduction diabetes is a major public health burden in many countries around the world the number of people with diabetes has risen rapidly over the last few decades and currently there are around 425 million people with diabetes globally 1 2 in addition to those who have been diagnosed with diabetes there are a large number of people with undiagnosed diabetes 3 the prevalence of undiagnosed diabetes is increasing not only in lowandmiddle income countries but also in developed countries and it can be costly and harmful for the individual as well as for communities and health care systems 4 early detection of people with undiagnosed diabetes is important as it enables them to manage their level of diabetes early on and to have a better quality of life by preventing or delaying the serious life threatening complications of diabetes such as heart disease stroke blindness kidney disease and amputation 5 6 7 the world health organization and other health care organizations such as centres for disease control and prevention and the national institute for health and clinical excellence recommend several different screening tools to identify people with diabetes 5 8 9 these include risk scoring tools and biochemical tests such as urine glucose random blood glucose fasting plasma glucose glycated haemoglobin and 75g oral glucose tolerance test 10 however it is difficult to carry out biochemical tests in mass screening programmes as most of them have a lengthy processing time require patients to fast overnight require commitment of nursinglaboratory staff can be expensive to conduct in some areas of the world and some people may not have access to these tests right away 10 whereas noninvasive risk scoring tools can be used as the first step in mass screening programmes and as a selfadministered tool for public for example the diabetes uk encourages people to use their online selfadministered noninvasive diabetes risk score in identifying the risk of diabetes 7 using such tools is useful not only for individuals to make informed lifestyle changes but also for the society and for the healthcare systems as it can prevent or delay serious complications of diabetes among the public downloaded by university college london from at 122719 for personal use only diabetes technology and therapeutics evaluating the performance of the indian diabetes risk score in different ethnic groups this paper has been peerreviewed and accepted for publication but has yet to undergo copyediting and proof correction the final published version may differ from this proof however current evidence on the performance of similar scores developed in lowand middleincome countries is rare specially in relation to their applicability in other populations and settings for example in 2005 the madras diabetes research foundation developed the indian diabetes risk score to triage people with undiagnosed diabetes 11 12 13 this was derived from the noninvasive risk factors identified in the chennai urban rural epidemiology study 11 which include waist circumference family history of diabetes age and level of physical activity 11 compared with other noninvasive diabetes risk scores developed for indians 14 15 16 idrs is the most commonly externally validated tool in a large number of studies across india 13 1627 it has been identified as a costeffective simple and easy to use tool mainly in resource restricted settings according to the mdrfidrs model development study by mohan et al the sensitivity and specificity of idrs is 725 and 601 respectively 11 several other studies conducted in different regions of india has shown that the sensitivity and specificity of idrs in identifying undiagnosed diabetes can vary between 508 975 and 176 917 11 13 1627 despite these existing studies from india the performance of mdrfidrs score has not yet been evaluated in other settings or among other ethnic groups mdrfidrs score is also likely to be applicable among american as it was initially developed using the risk factors recommended by the american diabetes association 11 however its performance among american has not yet been formally evaluated there are numerous diabetes risk scores available for american but most of them require some form of clinical measurement such as blood pressure level cholesterol level fasting plasma glucose level etc and hence it is difficult to use them in mass screening programmes 28 29 whereas idrs score is a noninvasive risk score that requires only four variables in addition a substantial percentage of people with undiagnosed diabetes in india 30 as well as in america 31 reported to have no contact with a primary care provider this emphasises the importance of noninvasive diabetes risk scores that can be used in mass screening as well as a selfadministered tool in both settings moreover people with undiagnosed diabetes are likely to be unevenly distributed in different ethnicracial and socioeconomic groups 32 for example the agestandardized percentage of undiagnosed diabetes cases among hispanics and nonhispanic asian are reported to be higher than all other racialethnic diabetes technology and therapeutics evaluating the performance of the indian diabetes risk score in different ethnic groups this paper has been peerreviewed and accepted for publication but has yet to undergo copyediting and proof correction the final published version may differ from this proof groups in america 32 hence it is important to assess the performance of risk scores in different ethnic groups separately therefore in this study we aimed to assess and compare the mdrfidrs scores performance among indian and american ethnic groups including hispanic nonhispanic white nonhispanic black and other american moreover we aimed to compare mdrfidrs scores performance with existing noninvasive american diabetes risk scores methods mdrfidrs score assigns weights for each risk factor and generates an aggregated weighted score between 0100 as shown in table 1 we used this weighted score in the national health and nutrition examination survey and chennai urban rural epidemiology study data to assess mdrfidrs scores performance in different ethnic groups including hispanic nonhispanic white nonhispanic black other american and indians nhanes is a repeated crosssectional survey which is performed in 2year cycles among a nationally representative sample of the us civilian noninstitutionalized us population 33 we used nhanes data for the years of 20032006 for adults aged ≥20 nhanes data on the age ethnicity family history of diabetes waist circumference and level of physical activity were obtained from relevant data files average level of physical activity each day was questioned in nhanes by providing study participants with four options to select the first is sits during the day and not walk about very much this option was matched with the idrs no exercise and sedentary work category the second and third options of nhanes stand or walk about a lot during the day but do not have to carry or lift things very often and lifts light load or has to climb stairs or hills often were matched with the idrs exercise or strenuous work category the third nhanes physical activity group do heavy work or carry heavy loads were matched with the idrs exercise strenuous work group study participants of nhanes were questioned if any of close relatives that is blood relatives including father mother sisters or brothers had diabetes the answer to this question was yesno and if they answered yes this was downloaded by university college london from at 122719 for personal use only diabetes technology and therapeutics evaluating the performance of the indian diabetes risk score in different ethnic groups this paper has been peerreviewed and accepted for publication but has yet to undergo copyediting and proof correction the final published version may differ from this proof matched with idrs both parents diabetic category otherwise it was matched with the idrs scores no family history category within the nhanes cohort people with type 2 diabetes were identified using their selfreported history of diabetes based on the question have you ever been told by a doctor or health professional that you have diabetes or sugar diabetes or if they had glycated haemoglobin ≥ 65 or if they were taking antidiabetes medication according to the medication inventory file people with type 1 diabetes were excluded from the study population type 1 diabetes patients were defined as those who have been diagnosed with diabetes before age 30 currently taking insulin and started taking insulin within one year of the diagnosis we also used data from the cures study which is an epidemiological study conducted between 20012003 among a representative sample of adults of chennai india 34 in phase 1 of this study the study participants with selfreported type 2 diabetes were identified moreover age and sex matched nondiabetes subjects and all participants with fasting capillary blood glucose of ≥ 110mgdl underwent an oral glucose tolerance test those who confirmed having 2hour plasma glucose levels of ≥ 200 mgdl were identified as newly diagnosed diabetes patients this survey collected data on age family history of diabetes waist circumference and level of physical activity in this survey physical activity was measured using an estimate for 24h energy expenditure 34 35 36 this estimate was generated using a questionnaire on the physical activity which included leisure time household chores work sleep sedentary activities and other common daily activities the 24hour energy expenditure was then categorised into vigorous moderate mild and sedentary physical activity levels we mapped vigorous energy expenditure level to exercise regular strenuous work category of idrs score moderate and mild levels into exercise regular or strenuous work category of idrs and sedentary physical activity level to no exercise and sedentary work category of idrs score descriptive analysis was carried out to identify the characteristics of the study participants with and without diabetes in each ethnic group chi squared test was used to identify any significant difference between the groups the mdrfidrs scores highest performance this paper has been peerreviewed and accepted for publication but has yet to undergo copyediting and proof correction the final published version may differ from this proof cutoff point was selected using the youden index the youdens index combines sensitivity and specificity into a single measure the area under the receiver operating characteristic curve and sensitivity specificity positive predictive value and negative predictive value of the relevant cutoff measures were used to assess the performance of mdrfidrs score within different ethnic groups we then reviewed existing literature on noninvasive american diabetes risk scores for identifying undiagnosed type two diabetes we excluded models developed using nonregression techniques due to the lack of transparency in these nonregression model development techniques especially in relation to reproducibility and validation in external datasets 37 38 we identified only one noninvasive american diabetes risk score fulfilling this criteria and it is the bang et al 39 score with sensitivity of 79 and specificity of 67 in detecting undiagnosed diabetes among american this score was developed using logistic regression modelling and included age sex family history of diabetes history of hypertension body mass index and physical activity level were included as variables in this score study participants were considered having family history of diabetes if their parents or siblings had diabetes physical activity was measured based on their answer to the question are you physically active idrs scores performance was then compared with this noninvasive american diabetes risk score nhanes survey uses a complex multistage probability sampling design to produce a nationally representative data set therefore we used nhanes survey weights to take the nhanes complex sampling design into account during the data analysis data management and analysis were performed using stata 15 results there were 11035 study participants eligible to include in this study and they were aged ≥20 did not have type i diabetes and they had complete data for all the variables considered in idrs score detailed participant flow diagram is given in appendices the study population characteristics were varied between the ethnic groups nonhispanicwhite participants had the lowest prevalence of diabetes whereas indian participants had the highest prevalence of downloaded by university college london from at 122719 for personal use only diabetes technology and therapeutics evaluating the performance of the indian diabetes risk score in different ethnic groups this paper has been peerreviewed and accepted for publication but has yet to undergo copyediting and proof correction the final published version may differ from this proof diabetes the mean age varied between 386 478 years the mean waist circumference varied between 834989 cm physical activity level among indians were relatively low when compared with the other groups 808 of indians were in the low physical activity level group whereas in the other ethnic groups 147 253 study participants were in the low physical activity group indians and nonhispanic black had the lowest and highest prevalence of family history of diabetes respectively as shown in table 3 age waist circumference and family history of diabetes were significantly associated with diabetes in all ethnic groups study participants with diabetes were older had higher waist circumference and had higher prevalence of family history compared to those who did not have diabetes and this trend was common in all ethnic groups there was no significant difference in the gender distribution among american diabetes and nondiabetes study participants however the distribution of gender among indian diabetes and nondiabetes study participants were significantly different with higher percentage of males in the diabetes group people with diabetes had lower level of physical activity compared to those who did not have diabetes and this difference was statistically significant in all ethnic groups apart from the otheramerican ethnic group the mdrfidrs score performed well among indians and american as shown in figure 1 and table 4 the auc for idrs score among indians was 07345 and the cut off≥ 60 had the highest performance with sensitivity and specificity of 802 and 573 respectively mdrfidrs score cut off ≥ 70 had the highest discriminative performance among hispanic nonhispanic white and nonhispanic black ethnic groups with sensitivity and specificity ranging between 701869 and 612722 respectively for otheramerican idrs score ≥60 was identified as the highest performing cut off with sensitivity and specificity of 948 and 489 respectively the auc for hispanic nonhispanic white nonhispanic black and otheramerican ethnicities was 07952 07749 08148 and 07872 respectively moreover mdrfidrs score had a high negative predictive value between 094098 for all ethnicities showing that those who get a negative test result for idrs are highly unlikely to have diabetes as given in table 5 the comparison of idrs score with existing american noninvasive score for undiagnosed diabetes showed that idrs score has almost the same performance as bang et al 39 score which uses six risk factors discussion this is the first study to assess mdrfidrs scores performance among american and to carry out a comparison of its performance among indian and american it has shown that this score performs well not only among indians but also in among american ethnic groups including hispanic nonhispanic white and nonhispanic black the mdrfidrs score can be used to identify people with undiagnosed diabetes in mass health screening programmes this risk score has a high negative predictive value for all ethnicities and therefore it is suitable as a triage tool to rule out those with a negative test result those who get positive test results for idrs can then be prioritised in providing further testing for diabetes to confirm their diabetes status the current study results are in line with the existing literature on mdrfidrs score performance in different regions in india 13 1726 and almost all studies showed that 60 is the optimal cut off point for the mdrfidrs score when definitions of physical activity and family history were not identical between the datasets and idrs score we tried to use the best available variable within each dataset and categorise them in the best possible way to achieve reasonable consistency across datasets and idrs score however the physical activity categories used in idrs score seems not specific enough to obtain accurate and comparable measurements across different datasets this may have resulted in the lower specificity of idrs score identified in the current study as well as in most of the previously conducted studies 11 13 1627 table 6 performance of idrs score in identifying undiagnosed diabetes according to previously published studies in india the mdrf idrs score was developed using the noninvasive risk factors recommended by the american diabetes association 11 and may explain the scores high performance in american ethnicities comparison of idrs score with existing american noninvasive diabetes scores showed that idrs has almost the same performance as bang et al 39 score moreover idrs score uses only four variables whereas bang et al 39 score uses six variables including selfreported hypertension which could be difficult to obtain accurately in resource restricted settings as people in these settings are less likely to be aware of their blood pressure levels 40 41 undiagnosed diabetes is a major public health burden not only in india but also in the united states in united states in 2017 there were 72 million people with undiagnosed diabetes and this represents 238 of people with diabetes 42 people with diabetes in the us incur average medical expenditures that are 23 times higher than that in the absence of diabetes and the total estimated cost of diagnosed diabetes in 2017 was 327 billion 43 most of these medical expenditure are due to the diabetes related complications and comorbidities 44 delayed diagnosis of diabetes can lead to people having more complications and in return this will cause more burden on the health care system 44 in india the economic burden due to diabetes is even higher and it is expected to rise particularly among the economically disadvantaged groups 45 hence early identification of diabetes though screening can have a substantial impact on reducing the costs associated with delayed diagnosis in both settings of diabetes which also facilitates early management and optimal control of diabetes and reduced risk of complications and associated economic burden for the healthcare system and society in this study we have shown that idrs performs well in different settings and in different populations regardless of the differences in population characteristics such as age distribution physical activity levels and family history weve used the same indian dataset that was used to develop idrs and this is likely to have slightly overestimated the performance of idrs among indians as risk scores tend to perform well in the development data set 38 46 despite this limitation of internal validation of idrs score it has performed well in the external validation carried out using the nhanes dataset providing that it has good performance in different settings and populations this study included a nationally representative sample of study participants from america and it combined two consecutive nhanes 2year cycles creating a large sample and therefore the results of this study are generalisable to the american population however in the nhanes dataset the family history of diabetes question did not distinguish between one parent or both parent having diabetes and therefore we allocated 20 points to those who said yes for family history of diabetes whereas ideally according to the mdrfidrs score 10 points should be allocated to those having a single parent with diabetes and 20 points to those with both parents having diabetes as shown in table 1 the lack of this information from the dataset might have altered idrs scores performance among american and future studies could investigate this by using an appropriate dataset downloaded by university college london from at 122719 for personal use only diabetes technology and therapeutics evaluating the performance of the indian diabetes risk score in different ethnic groups this paper has been peerreviewed and accepted for publication but has yet to undergo copyediting and proof correction the final published version may differ from this proof conclusion the madras diabetes research foundationindian diabetes risk score performs well not only among indians but also among hispanic nonhispanic white nonhispanic black and other american it can be used as a screening tool to help in early diagnosis management and optimal control of diabetes mainly in mass screening programmes in india and america author contribution the study was conceived by gn ss and mn the study was designed by the ornate india grant coapplicants mn and gn provided the statistical input mn drafted the manuscript and all authors commented on drafts and approved the final version downloaded by university college london from at 122719 for personal use only diabetes technology and therapeutics evaluating the performance of the indian diabetes risk score in different ethnic groups this paper has been peerreviewed and accepted for publication but has yet to undergo copyediting and proof correction the final published version may differ from this proof 5 hispanic cutpoint sensitivity specificity

 indian diabetes risk score idrs is a noninvasive diabetes risk score that uses only four variables and it has been identified as a costeffective tool for identifying undiagnosed diabetes among indians  this study has shown that idrs score has good performance not only among indians but also in other ethnic groups including hispanic nonhispanic white nonhispanic black and other american  idrs can be used in mass screening programmes by nonmedically trained health care workers and as a selfadministered tool among public to help in early diagnosis management and optimal control of diabetes in india and america

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background of the study the south african labour market has always been perceived to lack critical skills for nationbuilding and economic development over the years the nation has relied on european and other developed countries for expatriates to provide these skills there is a general perception that south africas present skills development system has mostly failed to meet the countrys skills requirements in south africa there are concerns about the economy and its potential to produce inclusive growth that will significantly reduce unemployment and poverty access to education and skills is a critical facilitator of economic progress therefore there is a need to provide a framework for the development of skills for highly competent individuals to occupy jobs that will be beneficial to all in a diversified and dynamic society such as south africa consequently skilled people could be able go into business for themselves and create incomegenerating companies to support their families and grow to generate job possibilities furthermore in a climate of fast economic structural change persons with skills are more likely to be able to adapt to changing economic requirements and therefore remain employed a lack of education and skills characterises the south african labour market and is reflected in several worldwide indexes many people who drop out of school do so without receiving fundamental knowledge acceptable qualifications are needed by some employers before any recruitment is done but vocational credentials at various national qualification framework levels do not fully equip learners for the workplace the low fundamental education basis in south africa is influenced by a combination of factors including inadequate funding overcrowded classrooms a lack of qualified teachers outdated teaching methods socioeconomic disparities high dropout rates limited access to technology language barriers insufficient parental involvement and cultural and societal factors in addition the skills system is underperforming often seen as failing to provide the necessary skills for both new entrants and existing employees 2013 south africa has 26 universities that graduate thousands of students with various degrees and qualifications yearly yet the number of unemployed youths constantly increases the quarterly report indicated a 349 unemployment rate in the first quarter of the year the statistics show that 24 of the total unemployed people were graduates however in 2021 the department of water and sanitation brought in 24 cuban engineers to help with infrastructure challenges and exchange knowledge likewise in the preceding year about 200 doctors were brought from cuban to south africa to help fight the coronavirus why were south africans not used when more than 50 of universities produce doctors and engineers yearly how do we justify the lack of critical skills south african graduate doctors and engineers need to tackle the countrys economic needs with their academic knowledge the common practice amongst academic institutions is to develop an educational curriculum based on existing knowledge and practice however existing knowledge may be irrelevant in certain situations especially in this generation where learning and new challenges constantly evolve and the workplace is expected to adapt as much as there is always a demand for new skills in the workplace the academic knowledge provided by educational institutions is also expected to be updated in addition academic institutions are expected to find common ground where knowledge can be transmitted to meet the demands of the workplace the skills gap will continue to widen as long as knowledge is acquired in isolation likewise unemployment will increase as much as academic knowledge fails to be converted into workplaceneeded skills some people have had to devote quality time to obtain their university degrees simply because some jobs require them to do so while past generations may have had only one job throughout their lives it is now common practice to have multiple jobs and careers with the development of the economy the upcoming generations may expect to have a variety of positions and vocations throughout their professional life there is an emphasis on balancing what is studied and what is required to do the job effectively most university graduates are underemployed due to the mismatch between academic qualifications and the workplace skills requirement visible underemployment refers to those forced to work fewer hours than they would want these people are looking for or wish to work longer or fulltime hours another description of underemployment is people doing work that requires a lower qualification than the one they have acquired the most disturbing aspect is that graduates are struggling to transform their academic qualifications into employable skills hence the study explores the gaps between educational qualifications and the workplace needs of south africa and global work demand and ways to close these gaps to improve the human capacity development of the nation for economic enrichment the study will debate how the academic qualifications offered by south african universities and other higher academic institutions can be used to meet the demand for skills needed for economic growth and reduce unemployment among youths the study will discuss different educational structures in south africa and their relevance to the employability of citizens also the south african national qualifications framework overseen by the south african qualification authority will be compared to relevant similar bodies in developed countries kappoabidemi and ogujiuba reckon that the corporate social responsibility of higher education institutions particularly in south africa should focus on the educational and skill development of historically disadvantaged individuals and on providing employment opportunities for graduates the hrdc acknowledged that the present skills development system has mostly failed to meet south africas skills requirements likewise various challenges within the education system inhibit it from functioning effectively to address the workplace knowledge skills and capabilities of fresh graduates of heis heis in south africa have focused on massifying education since the onset of democracy in 1994 however as much as the heis should be accessible to all quality cannot be compromised class sizes are overwhelmingly large in the current higher education system lecturers struggle to control the classes meaningful practically oriented engagement is almost impossible in an overpopulated classroom environment adetiba and tanga and maphosa acknowledged that contrary to expectations some south african universities may not achieve the anticipated improvement of the social order because of the problematic implementation of policies addressing these educational scenarios the study aims to critically examine the content of the current academic qualifications offered in south africa and their contributions to the national skills gap the nqf overseen by saqa will be used as a foundation for discussing the content of the academic qualifications offered in the country hence the study has the following objectives • to reconstruct decoloniality and explain the relationship between academic qualifications and national skills needs • to explore various ways of integrating current academic qualifications offered by educational institutions in south africa into the national skills gap literature review the decolonial theory is significant to the understanding of our study the theory supports the contribution of new knowledge of indigenous systems and how the south african educational system could positively benefit from this phenomenon according to gyamera and burke decolonial theory supports the acquisition of skills by challenging traditional westerncentric knowledge systems and advocating for a more inclusive and diverse curriculum that incorporates indigenous and nonwestern perspectives thereby enabling learners to develop a broader and more culturally sensitive skillset this approach encourages critical thinking creativity and a deeper understanding of global perspectives ultimately enhancing individuals capacity to navigate an increasingly interconnected and diverse world these values are encapsulated in the critical crossfield outcomes of the nqf but are rarely integrated into actual learning content of heis however the overemphasis on tests and examinations to assess knowledge limits the acquisition of skills attributed to the knowledge kolb acknowledged that skills need to be related to future workrelated endeavours the configuration of decoloniality is to delink the eurocentric perception of thoughts for indigenous concepts that are thoughtprovoking independent and valueoriented the need emerges to rewrite the trajectory of oppression and colonialism that the subjugated suffered as an academic discourse though it is extremely difficult to emancipate people from traditional ways of thinking decoloniality challenges the ongoing economic constraints caused by harmful past practices and strong western influence according to ogunyemi decoloniality is a systematic incorporation of thoughts that enhance liberation in the economic and the socialcultural context it is a conscious mindset phenomenon that aims at eliminating the monopoly of knowledge and imperialism in the social systems he further emphasises that decolonising knowledge is an academic and intellectual endeavour that promotes the use of afrocentric perspectives to challenge western dominance and oppression in education this aligns with spivaks idea which emphasises the importance of rejecting the belief in white superiority to promote the dignity and success not only of black people worldwide but also the development of africa as a continent mignolo vallego and quijano unapologetically posit the notion that european epistemology has lent credence to the social and economic inequality of the oppressed in society though the origin of decolonial theory can be clearly traced to latin merica it significantly reflects the cultural ethos of contemporary deprived societies it also reflected the depraved societies of africa and southeast asia and other postcolonial settings in the world mignolo valtego and quijano joined forces to deconstruct the western matrix of power using the decolonial lens as a drastic shift from the subjugation of the weak to constructively create a new epistemology of liberation and awareness that should finds its roots in educational life this new approach is a configuration of originality underpinning the reconstruction of awareness and new knowledge which can revolutionise education in south africa african countries will obviously benefit from educational reconstruction that contributes to reflective observation and the enhancement of learning processes in educational development reflective observation is a skill or method of learning that calls for reflection or observation on recently experienced events understood through tangible experience the action allows the learner to reflect on the learning experiences that have taken place the learner expresses their opinion about the learning by asking questions and discussing the experience with others bouw et al posit that reflective observation happens through integrative learning because aspects of school and work must be purposefully blended within the learning environment a curriculum that focuses on vocational education affects learning environment design at the intersection between school and work intentionally created learning environments or systems include coaching by professionals from occupational practice on genuine goaldirected work activities and the provision of physical spaces where students can apply their academic knowledge in developing their skills furthermore observational learning is the process of learning by observing the actions and results of others under specific conditions in contrast to imitation observational learning entails more than copying what others do when stakes are high students need to be able to follow evaluate and learn from observed behaviours and consequences dean explains that observational learning can be achieved through workintegrated learning across all disciplines qualifications and academic institutions the workplace or community is a place for wil where learners can observe and participate in transferring theoretical knowledge into actual practice ma et al maintains that observational learning develops the understanding of a learner reflective observation is closely related to situational learning which acknowledges that learning occurs best when it takes place in the context in which it is applied sociocultural contexts need to be considered in applying knowledge in situated environments in south africa learners work can be reflected in their active life experiences to integrate them into the new knowledge that is required to address the diverse needs of the economic environment another factor to note is abstract conceptualisation which is the notion of developing abstract concepts that can be generalised and applied to various situations the conceptualisation of knowledge is a learning and teaching method that processes knowledge through a systematic thinking processthe learners or facilitators ability to apply the abstract concepts in practice and understand what it means to work in an actual situation will enhance the knowledge of the learner the national focus and concerns over the years have been the issue of skills gap and skills development 1 shows that educational qualifications needed by the labour market can be achieved at any level of education likewise the skill gaps can be bridged at all stages of learning provided the skills are integrated into the theoretical knowledge active experimentation according to hernandezmarch et al higher education policies are increasingly included on government agendas at both the national and supranational levels higher education is critical for a countrys social wellbeing and economic prosperity a countrys ability to compete in todays knowledgebased global economy depends on a stable supply of highly qualified workers a sustainable system of research and development and an efficient mechanism for transferring knowledge from universities and public research organisations to the business network this shows that heis are more focused on knowledgebased education than skills acquisition however there is a need to find common ground between theoretical knowledge offered by academic institutions and practical knowledge required by the economy to bridge the skills gap the theoretical framework adopted for the paper encourages a practical adaptation of theoretical knowledge whereby the heis provide an avenue for knowledge to be practised the conceptual reality is that academic institutions and qualifications in south africa are structured for various purposes from which they are not allowed to deviate however the skills gaps could be addressed using multiple means rather than focusing on baseline academic qualifications provided by tertiary institutions mkhonza and letsoalo maintain that there are two ways for organisations to fill their skill gaps either by upskilling or hiring upskilling requires training the existing workforce in the necessary skills while hiring means appointing a new person from outside the organisation that possesses the needed skills the important point is that the skills have to somehow be acquired from some source academic qualifications in south africa employers in south africa and around the world want graduates who are ready to work the ongoing debates about graduates from higher education institutions lacking skills and knowledge have increased employers scepticism about graduates ability to perform effectively in the workplace once hired it is expected by various stakeholders that educational institutions like schools colleges and heis should prepare individuals for life via skills development at the most basic level such development which includes teaching reading and numeracy skills aids in creating work prospects the human capital paradigm states that contrary to popular belief the number of years spent in education improves ones capacity to find work however it is argued that skilled worker unemployment is complex and linked to factors such as educational quality lack of experience discrimination and inflexibility this view confirms that unemployment is a socioeconomic issue that is detrimental to economic welfare and output and diminishes human capital there are prominent players in the area who are impacted and influenced by the qualification system schools universities companies and learning centres are examples of providers employers fund a significant portion of adolescent and adult workrelated training and education and as gatekeepers they may encourage facilitate or prevent access to learning a qualifications framework is a tool for developing and categorising qualifications based on learning levels criteria this collection of standards might be hidden inside the qualifications descriptors or made apparent through a set of level descriptors the scope of frameworks may be broad encompassing all learning outcomes and routes or narrowed to a specific sector such as early childhood education adult education and training or a specific vocational field some frameworks have more design features and a more rigid structure than others some have a legal foundation while others represent a consensus of social partners viewpoints similarly behringer and coles describe a qualification as a unit of recognised learning outcomes such as certificates diplomas degrees and licences academic qualifications that will enhance skills development and bridge the skills gap cannot be achieved without mentioning lifelong learning relevant to organisational needs and individual development lifelong learning is a personal activity one of the factors explored by this paper is how the qualification system influences peoples motivation inclination and ability to pursue more education lifelong learning is essential for adults but it also applies to school children students and working and nonworking individuals even the most developed nations have begun a quest to continually grow the educational system and improve the quality of education since education has attained a level that cannot be restricted to specific periods in the human lifespan the south african academic qualifications are described in terms of the nqf levels provided by saqa which could be achieved through different means the employers assume that the required knowledge and skills for the nation and businesses should be gained from heis the ten levels of national qualifications framework focuse on scope of knowledge knowledge literacy method and procedure problemsolving ethics and professional practice assessing processing and managing information producing and communicating of information context and systems managing of learning and accountability in order to align competence in both intellectual and academic skills of knowledge to analyse synthesis and evaluate information hence the nqf makes provision for alignment of knowledge to skills in principle but the process is not clear in practice however the universities are structured differently for various purposes universities of technology are more aligned with workplace skills acquisitions at the same time traditional universities are more knowledgeoriented and comprehensive universities offer programmes that could be either knowledgebased or skillsbased however reddy et al opined that basic education also plays a critical role in the labour markets education and training since most of the south african workforce does not have tertiary education for this reason discussing the difference between knowledge and skills is essential according to boulet and conway knowledge is information gained through sensory input such as reading watching listening or touching knowledge is defined as familiarity with information and theoretical concepts knowledge can be transferred from one person to another or gained through observation and study likewise skills refer to the practical application of knowledge in a specific situation through sensory input and output and are developed through practice social skills for example are developed by engaging with people through observation listening and speaking continuous practice and engagement is probably the best way to master new skills alternatively workrelated skills can be acquired through workplace training and development programmes racial and institutional divisions and disparities have marked south africas higher education system van huyssteen acknowledges that the universities of technology formerly technikons were historically planned to award various careerfocused qualifications focusing on implementing existing knowledge skills and procedures such as national certificates and national diplomas before 1994 south africas technikons concentrated on educating skilled employees at the preprofessional level primarily engineering practitioners and technicians in various sectors such as biotechnology health sciences nature conservation auditing design film and video the distinction between technikons and universities is that traditionally technikons have a strong vocational focus including their closeness and interaction with workplaces and the lower entry requirements for most technikon programmes resulting in a more inclusive student body than that of more elite universities technikons industry ties were maintained through a structured and assessed system of workplace learning in most diplomas and a regular system of industrial advisory bodies attached to each programme universities of technology seems to be better equipped to award skillsbased qualifications the comprehensive universities in contrast were designed to confer degrees at the bachelor honours bachelor masters and doctoral levels for both types of institutions the standard 10 certificate level which is based on externally assessed and moderated tests on a national basis is the entry point into undergraduate qualifications the standard qualification for leaving school in south africa is grade 12 universities of technology accepted a grade 12 pass but universities demanded a full matriculation exemption certificate requiring particular course combinations and a higher minimum pass mark since the early 1990s technikons have been permitted to provide degrees the ranges of qualifications supplied by the two types of institutions have remained unique despite these developments and there has been difficulty articulating between the two systems according to the department of education changes in academic disciplines and knowledge fields typically influence university programmes from within it is generally a professional curriculum that emphasises the profession and the body or council regulating it many other university programmes will probably lack the external contacts necessary to launch and run technikontype programmes successfully in these situations institutions must simultaneously work on developing programmes and a network of partnerships with outside organisations representing business industry and the community in order to inform curriculum development create opportunities for cooperative and inservice learning and keep up with the evolving skill needs of the labour market the traditional universities are purely academic and offer bachelors degree programmes only for at least three years the admission criteria for a traditional university degree programme are slightly higher than that of a national diploma and national certificate and the focus is on acquiring workplace knowledge the focus of traditional universities is on general formative education with a theoretical orientation legal framework for academic qualifications in south africa the national qualification act of 2008 by saqa established the framework while the skills development act 97 of 1998 governs the national skill requirements the ten nqf levels are subdivided into gfetqsf and heqsf the gfetqsf comprises the general certificate at level 1 a grade 9 qualification an occupational certificate at level 1 elementary certificate at level 2 a grade 10 qualification and an occupational certificate at level 2 while the intermediate certificate is at level 3 a grade 11 qualification and national certificate at level 4 a grade 12 qualification and the occupational certificate at level 4 the higher education qualifications subframeworks and general and further education and training qualifications subframeworks are the two subframeworks that make up south africas ten nqf levels for academic qualifications the occupational qualification subframework which is comprised of eight levels is the third nqf subframework each framework represents the lowest rank to the highest rank of qualifications the qualification levels in south africa are governed by legislation that applies to academic and occupational certifications according to van huyssteen the creation and implementation of these frameworks reflect an audacious and daring undertaking to unite all learning under a single framework of standards and certificates based on outcomes with builtin quality assurance procedures nqf levels give prospective employees information about education and skills they make it easier to select the job applicant who is most qualified and fit for an open position as a result nqf certifications also assist students in making the right decision regarding their future careers the nqf describes the abilities needed for a particular employment field and how to acquire those skills reddy et al indicated that 1175 million persons in the south african labour force have less than a grade 12 certificate out of 15 million employed people in south africa showing that more than 70 of the south african workforce were employed at nqf level 13 which might be an inhibition to career progression and skills development in the workplace the heqsf includes a higher certificate at level 5 and an occupational certificate at level 5 a diploma and advance certificate at level 6 and an occupational certificate at level 6 a bachelors degree and an advance diploma at level 7 an occupational certificate at level 8 a bachelors honours degree postgraduate degree and a bachelor degree at level 9 and a doctorate degree nevertheless access to schools universities and tvet programmes has improved recently however quality is still difficult to come by which leads to poor academic advancement across all educational courses and low completion rates at academic institutions tvet colleges and universities consequently because of the attrition rate the accessibility to heis does not always translate to the necessary national competencies achievement in the school subjects of languages mathematics and science provides the basis for participation and achievement in technical themes in postsecondary education and training institutions and work rahmat et al identified four generic abilities that graduates must possess in order to succeed in the workplace academic connectedness personal management and exploration for holistic employees disciplinespecific talents should supplement these abilities according to griesel and parker the four main interconnected factors that affect employability are effective practices profound understandings rooted in a disciplinary base practical beliefs about ones own identity and selfworth and metacognition however as indicated above reddy et al assert that more than 70 of the countrys present workforce has less than a grade 12 education which demonstrates that the majority of south africans in employment left school before even acquiring the information and skills needed for the workplace durham claims that the nqf systems framework gives options and support to those without official qualifications who want to change occupations upskill themselves or those who dropped out of school before acquiring their grade 12 certificate the skills development act provides an administrative framework for creating and putting into effect national workplace and sector programmes to advance and improve the skills of the south african workforce in addition to the nqf act the skills development act 97 of 1998 was passed to correct a historical injustice in which some groups of people were excluded from educational opportunities this act made it possible to continue pursuing education and advancing ones abilities while working the act encourages employers to provide an environment at the workplace where people may actively learn new things and develop their knowledge additionally companies were mandated to contribute to the annual skills development plan for their workers under the skills development levies act 1999 which is how the learning is funded the employment tax incentive act 26 of 2013 was also introduced to address the unemployment problems among young people who were excluded from economic activity due to potential employers regularly voiced reluctance to recruit young job searchers mainly because young job applicants lack the necessary education credentials and experience a wellcrafted incentive is required and a sizeable financial commitment is needed to provide the essential expertise and experience national qualification frameworks an nqf is generally developed as part of a countrys development initiatives showing broad consensus regarding the form that qualifications should take and the desired outcomes of the initiative tuck explained that historically countries such as australia new zealand and south africa were the first countries to introduce national qualification frameworks between 1980 and 1990 while ireland malaysia namibia and a few other countries followed suit as the second generation between the late 1990s and early 2000s countries such as albania botswana angola lesotho and many others are still considering whether to have national qualification frameworks in addition to nqfs regions such as european union pacific islands and the southern african development community are considering having a regional qualification framework it is frequently asserted that nqfs will help certain countries regions and the global economy achieve their objectives from a broad policy perspective nqfs and international frameworks provide obvious benefits for related reasons employers and admissions administrators or registration officers will have a legally recognised framework to compare various qualifications if an nqf is available a european qualifications framework will assist regional organisations like the eu remove obstacles to unrestricted labour movement among member states for students an nqf will recognise credentials on a wider scale for example informal learning should theoretically also be eligible for accreditation by means of a recognition of prior learning policy young notes further important distinctions that need to be considered when analysing the possible drivers of the increasing interest in nqfs the first is the difference between often irrational expectations of what an nqfs implementation will achieve and nqfs as a practical response to real political economic and educational concerns like changes in labour markets and the growth and diversification of postcompulsory education the second distinction is between the general idea of an agreedupon set of qualities shared by a nation or group of nations and the widely varying ways the concept of a framework has been embraced in other nations beyond these distinctions the nqf was created to recognise management qualifications and informal and nonformal learning as indicated earlier a major global trend in modernising national education and training systems since the late 1990s has been the creation of nqfs the international labour organisations recommendation no 195 on human resources development education training and lifelong learning which was adopted in june 2004 recommended the adoption of an nqf as a means of promoting the development implementation and financing of a transparent mechanism for the assessment certification and recognition of skills typically a diagrammatical picture of the south african nqf is used to display and discuss it it shows the structure from the highest qualification to the general certificate research methodology the study used a methodical literature review that was carefully planned and carried out the skills gap in south africa has been the subject of research that looked at elements impacting the theoretical literatures of decolonising and educational degrees only articles that were released during the 10 years before the current study were deemed to cover current trends and to be pertinent additionally studies that looked at outside influences on the creation of academic curricula were also examined in publications research design and scientific literature search in order to seek classify plan and critically assess the literature in order to develop themes a hermeneutic outline was used the journal articles were located using a variety of electronic bibliographic databases databases from various disciplines and websites academic publications google scholar company blogs company websites emerald insight and aosis are all included in this database in a search engine the terms decolonisation educational requirements skill shortage and knowledge acquisition were entered with the use of these keywords the study was able to locate themes and gain a deeper understanding of the internal and external elements affecting employee performance to be further vetted all the structures were recorded in an ms excel spreadsheet the spreadsheet was examined more closely in order to categorise relevant prior research that is consistent with the goals of the current study to ensure that only papers that could contribute to the achievement of the goals of this study were examined the pertinent articles were carefully and purposefully chosen in this essay internal and external factors impacting employee performance served as the unit of analysis 95 percent of the articles that were chosen were released during the last five years because of this the review was best based on current empirical studies that concentrated on the variables driving the skills gap in south africa conclusion the research conceptualises the teleology of decolonisation in the description of south african educational qualifications in an attempt to unpack the dire skills shortages in south africa the paper demonstrates various educational qualifications and the inadequacies in meeting the skkills demand of the economy the history of education in south africa has developed from the colonial dispensation to the current system of educational qualifications in south africa the article suggests how decolonising knowledge could add a new dimension to the body politic of learners when new configurations are added that would make room for employable skills within the socioeconomic space of south africa using the decolonial lens the research showcases how indigenous knowledge could be incorporated into the educational domain which would invariably develop the south african educational system and make it relevant in the african cosmology

the research uses decolonial theory to delineate the conceptualisation of the academic qualifications provided by south african tertiary institutions and their relevance to closing the national skills gap decolonising the south african educational system represents a progressive approach that is new to both students and educators both government and employers acknowledge a skills shortage in south africa however the question of where the skills should be provided is unanswered graduates are expected to have specific skills before entering the labour market the study uses desktop research that focuses on secondary data to explore the phenomenon the research has two objectives to present a decolonial explanation of the relationship between academic qualifications and national skills needs and to explore ways of integrating current academic qualifications offered by educational institutions in south africa to address the national skills gap the study explores how the content of the national qualification framework and its relevance in skills development can be decolonised the study found that the existing educational qualification programmes in south african tertiary institutions are unable to address the skills gap effectively due to emerging needs highlighted in recent literature to address this issue there is a need to restructure academic qualifications to better align them with the countrys skill shortages or explore alternative approaches to aligning knowledge and skills the study recommends examining the national skills shortage beyond the higher education institutions academic structure and looking at other factors such as workplace discrimination in training and development collaboration between stakeholders employers and tertiary education institutions should be

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introduction central and eastern europe has seen sharp increases in hiv and sexually transmitted disease rates over the past two decades while central and southern parts of the region were only modestly affected former soviet countries have seen a particularly dramatic rise in std and hiv rates hiv increases were first found among injection drug users and were primarily related to their needle sharing practices however the epidemic increasingly affects the general population and sexual hiv transmissionalthough not yet the predominant modealready accounts for 42 of all new hiv cases in these countries 1 epidemiology of hivaids and stds in central and eastern europe the region has seen overall increases in hiv and std rates in the past two decades rises in stds were particularly sharp in several postsoviet states including russia ukraine belarus moldova and kazakhstan 2 for example the rate of syphilis soared from 4 cases per 100000 recorded in the mid1980s to 263 per 100000 by the mid1990s a roughly 62factors that are globally associated with dramatically increased levels of commercial sex work with illicit substance use and abuse and consequently with high rates of stds and hiv another enabling factor was generally increased tolerance of behaviors that were socially forbidden in the sovietera past such as commercial or casual sex and drug use some central and eastern european countries quickly introduced and implemented public health programs including needle exchange sex education and condom promotion in contrast effective measures of hiv prevention were not implemented in the timely manner in most postsoviet countries which still lack funding infrastructure trust within vulnerable community populations and political support as a result hiv epidemic trajectories in these subregions also differed while hiv epidemics in countries outside of the former soviet union have often been well managedand disease incidence and prevalence has increased only modestlylargescale and rapid hiv raises have occurred in many former soviet countries 11 large increases in std and hiv rates in the midto late1990s showed that postsoviet public health systems were poorly prepared to mitigate the consequences of these epidemics std treatment was historically provided by the state however the reach of these services was ineffective and was certainly inadequate to cope with large rises in stds and hiv prevention programs for atrisk populations were almost nonexistent and the scope of public health prevention activities still remains very limited especially in many postsoviet republics this was also partly due to a lack of mobilization of affected communities to confront hiv epidemics limited community infrastructure and community representation in public health decisionmaking and little experience and awareness of effective prevention measures even now 89 of the subregions hiv prevention funding is not directed to vulnerable community populations who are most affected by the disease 7 in addition educational systems often were not ready to implement sex education for example russia the country that has seen the greatest rates of both stds and hivstill prohibits school programs that provide education about personal protection against hiv and stds 12 as a result access to reliable information about protection related to sex or drug injection remains limited aids prevention ngos in central and eastern europe often function under difficult circumstances a regionwide ngo survey found that the most frequentlycited barriers to effective functioning and serving their communities are lack of funding governmental indifference or opposition aidsrelated stigma low hiv risk perception by communities and the presence of other pressing severe social problems such as war and poverty that make concerns about hiv and stds less salient than everyday social hardships 13 in general aids service providers had only limited capacity and resources to carry out hiv prevention programs on a wide scale to vulnerable populations in their communities however recent stories successful practices and developments are encouraging 14 under the aegis of global fund to fight aids tuberculosis and malaria ngos in several countriessuch as ukraine georgia and kyrgyzstansubstantially increased the scope and coverage of hiv prevention activities condom use is an important indicator of the effectiveness of existing hiv prevention education policies and measures the aim of this article is to review what is known about condom use levels and the prevalence of sexual risk practices in a variety of populations in central and eastern europe data resources for the current review in order to collect data for this review us national library of medicine and national institutes of health electronic bibliographic resources 15 were utilized and searched for all possible peerreviewed article citations related to hivaids risk behavior research in postcommunist countries in central and eastern europe and central asia all articles published between 2000 and 2010 were screened for a topical relevance namely any reference to condom use in either their measures or the results descriptions in paper abstracts potentially relevant articles were then further screened for inclusion of specific behavioral data of interest namely condom use in any population group within the region fiftysix articles resulted from this screening and were classified by study target population group table 1 lists these articles and describes the sampling frames of each study all but three articles were published in english adolescents and young adults were most frequently studied followed by injection drug users men who have sex with men commercial sex workers people living with hiv the roma ethnic minority group prisoners and labor migrants if multiple papers reported results from a single dataset they were counted as a single paper about onethird of all studies included in the review were based on research in russia and much smaller proportions represented other countries for nine countries no results were found as an outcome of this search in addition the search identified regional hiv risk behavioral research review articles that were not directly used as data sources although their findings were selectively used to support conclusions that resulted from the current research condom use among atrisk populations adolescents and young adults heterosexual transmission now accounts as much as 40 to 50 of all new hiv infections in russia and other countries in which idus were primarily affected in the late1990s and early2000s 1 a large crosseuropean review study revealed that by the age of 15 from 19 of adolescents in estonia to 47 in ukraine had sexual intercourse 16 even though condoms were reported to be the most common type of sexual protection they were used at last intercourse from 59 of the time by adolescents in ukraine to 76 in macedonia 16 a croatian study among youth between the ages 18 and 24 found that 41 of last intercourse events reported by men and 54 reported by women were unprotected 1718 an alarmingly low rate of condom use at last intercourse act was reported from poland where only between 11 and 27 of adolescents said that they used any kind of contraception 1920 rates of consistent condom use in adolescents and young adults were also low research findings showed that consistent condom use ranged from 7 in the russian province city of kostroma 21 to 29 in st petersburg 22 40 in budapest hungary 23 and 44 in moscow russia 24 oral contraceptives were also commonly used in the region 1625 indicating that a large proportion of young people view sexual protection as prevention against pregnancy rather than a measure to prevent hiv or stds 26 a study among croatian school adolescents surveyed in 1997 and 2001 revealed increases in condom use and consistency particularly among females although 40 still did not use condoms at last intercourse in the later sample 27 a similar pattern of more frequently engaging in sex but also more often using condoms between the 1990s and 2000s was observed among school adolescents in slovenia 2528 there are certain geographic differences with respect to gender and engaging in sexual risk behavior for example in the republic of georgia 40 of 14to 17year old malesand only 3 of females of the same agewere reported to be sexually experienced 29 this pattern is likely to broadly characterize subregions such as the transcaucasus central asia and also certain ethnic groups in central europesuch as roma 30 with traditions strongly prohibiting females from premarital sexual engagements in contrast over half of 17year old slovenian adolescents were sexually experienced 25 some studies found that the proportion of male youth paying for sex was as high as 30 in kazakhstan 31 qualitative research conducted in hungary and russia suggests that condom use declines quickly following first sex with a new partner and that reintroducing condom use in a relationship is difficult 26 street adolescentsincluding those orphaned homeless abandoned by their families or those who left their homes for other reasonsare particularly vulnerable to hiv and stds for example only 20 of russian street adolescents reported that they consistently used condoms and extremely high proportions of participants in these samples were hivpositive 3233 consistent with these findings homelessness predicted hivpositive serostatus among young injector drug users 34 unlike in other at risk populations heterosexual hiv transmission often occurs in stable regular relationships in which persons are often not aware of their partners risk behavior engagement andthereforedo not perceive themselves as vulnerable injection drug users idus are among the community populations most affected by hivaids particularly in former soviet republics hiv prevalence rates among idus are as high as 45 in estonia and russia 3435 in these circumstances condom use is the most important tool to prevent sexual transmission from idus to their sexual partners thus drug users are not only affected by hiv due to their own needle use risk practices but also constitute a bridge to the nonidu majority population in the former soviet union sharing needles and also engaging in unprotected sex are common among idus in this region particularly in russia 34 36 37 38 several studies among idus have been conducted in st petersburg one found that 41 of idus shared needles 70 had recently engaged in unprotected vaginal intercourse and most had multiple sex partners in the past 3 months 38 another study showed similar risk levels and also found that 44 of drug users engaged in sex with nonidu partners 36 finally a dyadlevel study found that most hivserodiscordant couples of idus continued to have unprotected sex 37 there has been no consistent pattern of findings related to the association between hiv positive status and condom use for example studies have found a negative association between hiv infection and condom use among idus in uzbekistan 39 a positive association in ukraine 40 and no association in an estonian idu sample 35 this is probably because transmission risk related to sharing needles overrides risk for contracting hiv during sex among current drug injectors in contrast younger age has been consistently found to predict hivpositive serostatus among idus across these studies overall the issue of unprotected sex and condom use among drug users in postsoviet countries has been much less frequently studied than idu injection risk practices this constitutes a significant gap in public health knowledge given the high proportion of hiv infections attributable to sexual transmission from hivinfected idus to their sexual partners although much lower hiv prevalence has been reported among idus in countries outside of the former soviet union such as 02 in czech republic 4142 and 05 in bulgaria 43 unprotected sex among drug users was common this is an alarming indicator of the potential for hiv transmission from idus to their sexual partners and beyond commercial sex workers the vulnerability of commercial sex workers has been welldocumented in a large number of studies injection drug use in eastern europe is intertwined with commercial sex work since selling sex is often a source of money used to pay for drugs when other sources are limited drug injection was reported by 8 of csws in estonia 44 10 in latvia 45 15 in serbia 46 and 25 in lithuania 47 in addition a history of engaging in commercial sex was reported by 37 of female idus in a sample in st petersburg russia 48 a general pattern of great hiv vulnerability has emerged from studies of csws in central and eastern europe inconsistent condom use by sex workers has been commonly reported across studies 45 46 47 49 50 51 higher std and hiv rates and more frequent unprotected sex particularly characterize streetbased csws while indoorbased csws are often more knowledgeable and use condoms more consistently street csws in turkmenistan reported use of condoms primarily when condom use was initiated by the client and barbased csws regularly use condoms only with firsttime clients 50 however their perception of hiv vulnerability was low in contrast a serbian study 46 found greater risk knowledge and risk perception among indoorbased csws but low levels of hiv awarenessand low condom useamong streetbased csws in addition engaging in streetbased sex work was a significant predictor of hivpositive serostatus in a uzbekistani study of csws 51 in samples of csws in latvia and lithuania the prevalence of biologicallytested stds was extremely high 4547 and onefifth the latvian study participants were pregnant economic hardship unemployment and poor living conditions were main reasons of engaging in commercial sex among csws in latvia 45 similar findings were reported from a lithuanian sample alarmingly a large proportion in the lithuanian sample were trafficked women who had engaged in commercial sex for over 10 years 47 taking into account high hiv prevalence rates among csws in former soviet countries their clients and other sexual partners are also vulnerable however little research among the latter groups has been reported to date men who have sex with men hiv risk among central and eastern european msm has not received adequate research attention condom use during anal intercourse is a primary indicator of risk level among msm this is because anal intercourse poses the greatest biological risk for hiv transmission from an infected to the uninfected partner and also because the behavior is widely practiced by msm in this respect a number of risk behavior patterns have emerged from the literature although hiv risk knowledge and awareness are generally high among central and eastern european msm these are not directly translated to safer behaviors a number of barriers need to be addressed to facilitate the adoption of safer behavior strategies among the most prominent barriers in the region are msmrelated stigma and discrimination as these produce circumstances that make it difficult to sustain sexual safety 52 high rates of unprotected intercourse have been reported in various studies throughout the region and msm account for a majority of infections in the regions central and southern countries 53 only 43 of a russianand a half of a hungariansample of msm reported using condoms consistently in the past 3 months 5455 twothirds of men in social network samples of hungarian and russian msm reported that they recently engaged in unprotected sex 56 rates of condom use at last intercourse reported among various msm samples include russia 54 estonia 57 hungary and russia msm networks 56 and slovakia 58 however these studies were conducted at different time points and do not show the dynamics of condom use over time the only condom use dynamic estimates were reported in a sentinel surveillance study in slovenia where condom use at last intercourse declined from 81 in 2004 to 66 in 2008 59 indicating an alarming need for additional hiv prevention efforts decisions by msm about whether condoms are to be used often depend on partner type greater levels of condom use are usually reported during sex with casual partners and much lower condom use with regular partners 58 in a hungarian sample being in a steady relationship was associated with lower condom use rates 55 participants in a hungarianrussian social network study indicated that 55 of their last anal intercourse was practiced with a casual partner 56 81 of msm in a croatian sample said that their most recent anal intercourse with a casual partner was protected but only 56 reported consistently using condoms with casual partners in the past year 60 other risk factors among msm in the region include having multiple sex partners within a short timeframe 56 for example 53 of participants in a russian msm sampleand 25 of men in a hungarian samplehad sex with multiple partners in the past 3 months 55 this reflects frequent concurrent or shortterm serial relationships for example russian msm reported that their median length of a sexual relationship was 10 months but onethird of men in primary relationships had outside male partners and almost half had outside female partners in the past 3 months 54 another risk factor of hiv risk among msm in the region was engaging in commercial sex for example 23 of msm in russia reported that they sold sex and 45 of them had recent unprotected anal intercourse 5461 however the representativeness of these findings is unknown because there has been little research on commercial sex engagement among msm in this world region bisexual behaviora potential bridge to a heterosexual virus transmissionhas been commonly reported among msm in the region and the use of condoms among bisexual men is also inconsistent both bisexual identity and behavior were commonly reported by msm in estonia half of an msm sample reported being bisexual 57 in a russian sample 29 of msm had sex with partners of both genders in the past 3 months in hungary 26 of msm had femalein addition to their malepartners in the past year and used condoms only 23 of the time with them 55 a similar level of recent bisexual behavior was reported in a russian sample 5462 in croatia only about 20 of behaviorally bisexual men used condoms consistently 63 finally substance use has been commonly reported by msm often including illicit drugs 545657 use of recreational drugs was greatly associated with engaging in unprotected sex 56 this was not found among croatian msm 63 although very low response rate may have influenced sample validity other impoverished community populations several other populations have been reported to be behaviorally vulnerable to hiv for example incarcerated persons are at elevated risk due to injecting drugs engaging in unprotected sexual practices and sex in exchange for money or valuables as well as using nonsterile methods of tattoo engraving and piercing 64 65 66 correctional facilities often lack provisionsand fail to provideclean needles and condoms as the result in countries such as ukraine hiv prevalence among prisoners became as high as 32 64 the scaleup of prevention programs in correctional facilities as well as hiv care provision are needed in much of the region public health concerns associated with labor migration have been documented worldwide russia is central and eastern europes leadingand is the entire worlds second leadingdestination country for international labor migrants migrants risk is often related to their prolonged stays apart from their spouses and engaging in sex with casual partners often with commercial sex workers 6768 croatian migrantsseafarers and construction workers reported multiple sex partners in the past year and 45 of migrants said that their last intercourse with casual partners was unprotected 67 in a russian study of labor migrants from former soviet republics of central asia and eastern europe onethird reported multiple sex partners in the past three months 68 condom use rates were as low as 52 with casualand 35 with permanentsexual partners although limited scope of research does not allow one to identify the extent of representativeness of these findings they indicate that labor migrants should be reached by stdhiv intervention programs roma constitute the largest ethnic minority population in central and eastern europe although roma have not been widely affected by hiv to date many social factors and risk behavioral data indicate their potentially high hiv vulnerability studies among bulgarian roma men found very high rates of highrisk behaviors 6970 most men in a roma community settlement sample in sofia bulgaria had multiple sexual partners in the past 3 months and 77 did not use condoms during their most recent vaginal intercourse 70 almost threequarters of men in this study practiced anal sex with females and only one in four of these acts were protected over onequarter of roma men in the sample reported engaging in sex with men at some point in addition to their heterosexual behavior and 10 did so in the past three months finally 16 of roma men soldand 32 paid forsex in the past three months distinct aspects of roma hiv vulnerability are associated with gender roles and expectations 30 as such roma men have great sexual freedom before and during marriage and exercise relationship power and control roma women are expected to maintain virginity before marriage and then sexual exclusivity to their husbands gender power dynamics need to be taken into account in condom promotion and risk prevention programs among roma people living with hiv a limited body of research on condom use among plh has been reported to date from the central and eastern european region only three studiesone from zagreb croatia 71 and three from st petersburg russia 72 73 74 have systematically recruited crosssectional plh samples from aids service provider settings with respect to transmission risk behaviors 20 of croatian hivpositive msm reported unprotected intercourse with seronegative or statusunknown partners in the past 6 months and half of them reported unprotected intercourse with multiple casual partners of unknown status heterosexual plh in the sample commonly reported unprotected sex with their regular partners only half of participants in an hivpositive idu sample from russia used condoms at their last intercourse regardless of their partners serostatus 74 two other russian survey studies among plh one conducted in 2002 72 and another in 2009 73 found high rates of unprotected sex by persons aware of their positive hiv status most plh had sexual partners of seronegative or unknown status with a mean of 58 partners 72 in both studies about a half of participants in the samples reported engaging in some unprotected intercourse and a mean of 30 of intercourse acts were unprotected the subsample which reported the greatest level of sexual transmission risk behavior were hivpositive idus who are also msm and the lowest level was reported by plh who reported heterosexual hiv exposure discussion international calls for preventive action long emphasized the need for urgent measuressuch as needle exchange and methadone treatment roll out programsto curb the hiv epidemic among idus while such measures were quickly introduced in some countries othersprimarily postsoviet countriesdelayed the initiation of funding and necessary policies hiv prevention programs often lacked political support were conducted on a limited scale or simply did not exist barriers to effective hiv prevention programs vary across the region however they often include lack of infrastructure dedicated for hiv prevention political or religious opposition that often considers condom promotion or needle exchange as immoral continued high stigmatization of vulnerable groups that makes them hard to reach by community programs and insufficient coverage of existing prevention programs ngo funding in most countries is scarce and unstable often relying on international donor agencies rather than national governments 13 initially fueled by unsafe drug injection practices in postsoviet countries hivaids growth is now becoming increasingly driven by sexual hiv transmission in other parts of central and eastern europe hiv remains primarily characterized by sexual transmission the findings reviewed here show that idus often engage in unprotected sex which illustrates that sexual partners of drug injectors are at substantial risk since idus also often sell sex to buy drugs clients of csws are also are at high risk and constitute a bridge group to the general population for these reasons heterosexual risk exposure in central and eastern europe has expanded beyond those who themselves engage in commercial sex or inject drugs although the epidemic remains concentrated hiv prevalence rates in russia and ukraine already exceed one percent of the general population the current review identified population groupsand also geographic areasthat require the scaling up of condom promotion programs and expansion of their coverage to reduce the incidence of hiv and other stds of a particular concern the lowest rates of condom use were found among the most socially disadvantaged lowincome population groups which suggests that to be effective hiv prevention programs need to be embedded in broader social development programs so to address basic needs of the target population groups in many western countries msm account for the greatest proportion of hiv infections hiv prevalence among msm in central and eastern europe has not reached the very high prevalence levels typical of the west however findings identified in this papertaken togethersuggest that msm in central and eastern europe are in continuous need of highimpact prevention interventions programs to promote condom use among msm need to scale up and to engage communities into this endeavor haart rollout has reduced hivrelated mortality rates and increased life quality and expectancy among infected persons however longer lives better health and continued sexual behavior of hivinfected individuals underscore the need for secondary prevention programs for them to reduce transmission to others high levels of hiv risk transmission behaviors were found among plh programs that address life mental health and social development needs of plh must be developed and implemented throughout the region conclusions resulting from the review of available literature call for immediate action • condom promotion programs need to scale up to levels that reach vulnerable population groups including those hard to access by conventional counceling methods • implementation of programs to promote safer behaviors to curb hiv in communities integrated with programs that address social and community development poverty social disadvantage discrimination human rights and social inequality • developing infrastructureand allocating appropriate financial resourcesneeded to provide effective and affordable public health services to prevent and treat hiv and stds with a particular focus on specific health issues of women of msm and other vulnerable groups • scaling up research to further study hiv prevention needs of vulnerable populations and to develop and implement effective risk reduction programs • advocating for political and public support to overcome existingand protect against futureobstacles to successful hiv prevention several limitations of this literature review must be noted the analysis of data from the reviewed articles was not formally performed as a metaanalysis this paper included the review only of peerreviewed articles and did not include data that was published in forms such as nonpeerreviewed conference abstracts public reports and presentations some articles were not included into review if they did not provide sufficient details or if it was not possible to interpret presented data further research is needed to address these gaps other limitations were not under the control of the author for example the body of the identified literature lacked findings from several countries andthereforeneeds of their vulnerable populations were underreported in the literature the studies reviewed reflect selfreported data that often is subject to bias typical for the sexual behavior survey studies in addition behavioral levels were assessed at different time points and may not necessarily reflect the current picture finally some of the articles lacked sufficient description of the sampling methods and a substantial proportion of studies relied on convenience or small samples findings from these studies should be interpreted with caution since their generalizability is unclear central and eastern europewhich has experienced many political economic and cultural transitions over the past two decadesis in a position to implement a large variety of effective measures to reduce hiv incidence comprehensive approaches have already been successfully implemented in some countries of the region but still remain needed in others political will is needed to overcome policies that presently constrain effective hiv prevention approaches limit opportunities for public education and produce stigma roster of studies included in the review country in which data was collected references sampling frame n remarks adolescents and young adults regionwide godeau et al 16 crossnational crosssectional school probability sample 33943 age 15 only data from central and eastern european region was used croatia stulhofer et al 17 bozicević et al 18 national multistage stratified probability household sample 1093 age 1824 poland woynarowska et al 19 crosssectional school representative sample

the epidemiological trend of increasing hiv incidence rates due to sexual transmission in central and eastern europe has been documented the current review analyzed research articles that report on a wide spectrum of vulnerable populations from this world region studies of injection drug users commercial sex workers men who have sex with men adolescents and young adults all reported inconsistent condom use however these patterns varied across populations and geographic areas populations in former soviet countriesmost affected by hivalso often appeared to have lower condom use rates intensified comprehensive and locallytailored measures to curb sexual hiv transmission are urgently needed social development programs need to incorporate hiv prevention

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introduction the covid19 pandemic has a global impact on the planet lifestyle work and communication transform significantly physical contact is minimized and people have turned to online communication business meetings school and university classes conferences theatre performances concerts and private communication have all derive into virtual form the pandemic crisis also put on challenges health systems globally many countries have not been able to handle the pressure of requests for treatment of covid19 and individuals with other pathological conditions people are in a constant state of uncertainty and fear and search for support these circumstances caused the internet has become a valuable source of information about covid19 and other diseases and the concept of ehealth spread much faster and broader than before however information about covid19 has also been labeled as infodemic which means an excessive amount of information about the problem that is typically unreliable spreads rapidly and makes a solution more difficult to achieve unreliable information can endanger the health and lives of those who rely on it furthermore they may lead them to actions such as public demonstrations misuse of drugs remedies or induce fear from conspiracy theories inducing both panic and xenophobia in some cases as a result of the circumstances mentioned above locating trustworthy online health resources and using available information effectively is extremely important in this process health and ehealth literature have one of the critical roles in line with the trend the european economic and social committee supports the european commissions attempts to put digital health literacy as a highpriority in the ehealth agenda the eesc also emphasizes that various generations need different approaches to improve ehealth literacy depending on their utilization of digital tools in everyday life it also points out the advantages that eservices provide in correlation with fully understanding the provided information the who european region office also published a comprehensive overview of ongoing projects and their outcome in its whohenreport57 the documents conclusion states that health literacys main factor is the growth of skills through formal educational systems and lifelong learning the republic of serbia also started introducing ehealth in the serbian medical system in line with strategy for development of information society in serbia until 2020 with the concept of integrated health information system the ihis is a central electronic system which contains all medical and health data of patients data of health workers and associates data of health institutions health interventions and services performed in health institutions data of electronic instructions and electronic prescriptions appointment information for specialist examinations diagnostic procedures and surgical interventions with the topdown approach serbia has opted for a modern approach to health and healing on the other hand serbia citizens developed the need and habits of internet support in practically every aspect of their lives including healthcare their ability to find useful information schedule doctor appointments and similar activities were beneficial during the covid19 lockdown the entire population was exposed to health risks on various grounds in addition to the direct infection with the coronavirus there was an increased risk of difficult access to the healthcare system due to the focus on covid19 patients clinics closure and free circulation restrictions lockdown and social distancing affect all sectors of the serbian economy but not equally the sector of small and micro enterprises is the most vulnerable at the same time women entrepreneurs position is particularly complexed in serbia in a society that respects traditional values women continue to be a pillar of the household and still have the principal responsibility for doing everyday household chores secons published a survey that shows that one or more women cook in 73 of households wash dishes in 67 of households wash clothes in 79 of households and control childrens school homework in 556 of households as a result female entrepreneurs are recognized as an extremely vulnerable group therefore we believe that appropriate behavior and the level of ehealth literacy can greatly facilitate health and family care it is particularly important and in line with the fact that women should have equal opportunities to gain skills and abilities like men through lifelong learning the development of technology has only emphasized this need bearing in mind that many female entrepreneurs are still keeping their head in the sand for knowledge about informationcommunication technology following the rationale that ehealth refers to a broad range of health care services and health information delivered through or enhanced by information and communication technologies in this paper we analyze the level and determinants of the ehealth skills of female entrepreneurs in serbia in particular current utilization of the ehealth opportunities by the female entrepreneurs in serbia and comparison with other women and male entrepreneurs and association of the sociodemographic factors with ehealth skills of the female entrepreneurs in serbia literature review in the last few decades the increasing popularity of using the internet to find healthrelated content has spurred the development of the ehealth concept one of the fundamental assumptions of this concept is skills that enable users to find on the internet and accurately interpret available health information ehealth literacy in that sense ehealth literacy is defined as the ability to seek find understand and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem eysenbach argues that the accumulation of ehealth literacy is essential for ehealth behavior it determines whether and to what extent individuals can benefit from ehealth participation which refers to a persons engagement with various health services and information delivered or enhanced through digital technologies the first dilemmas about the reliability of medical information available on the internet emerged at the end of the last century when these services became increasingly in demand eysenbach even uses the expression anarchic nature in the sense of available information quality impicciatore et al point out that unrestricted retrieval of data on diseases treatments and medicines requires taking responsibility for healthcare decisions the users need to have in mind that this information lacks validity and consistency in many cases even at that time it was a very sensitive issue since more than 60 million individuals in the us searched for health and medical information on the internet in 1998 and the need for appropriate knowledge and literacy become to emerge the level of ehealth literacy directly impacts ehealth behavior including the use of information technology to search the internet for health information make appointments with physicians purchase medicines online or participate in support groups the first ehealth literacy conceptual model is proposed by norman skinner it comprises six core skills or literacies traditional health information scientific media and computer literacy and it is represented by the lily model each literacy type can be measured separately or combined into two dimensions analytical skills and contextspecific skills the analytical skills combine traditional literacy and numeracy media and information literacy while contextspecific literacy includes health computer and science literacy table 1 presents a brief explanation of literacies based on the model norman skinner develop a measurement scale eheals as a methodological instrument they use a selfassessment questionary with a fivepoint likert scale of agreement and factor analysis the research covers 664 participants aged between 13 and 21 and found that the tool can identify the level of internet health information usefulness among different categories of respondents hsu chiang yang propose the integrative ehealth model to study taiwan students ehealth literacy the model tests hypothesis on the correlation between individual factors ehealth literacy and health behavior they introduce a twelveitem questionnaire with a fivepoint likert scale of agreement conduct research and collect 525 answers the results show that ehealth proficiency has an intermediate role in the relationship between demographic and individual factors and health behavior also the literacy level was higher among respondents with better health status who studied clinical fields or had a particular concern for their wellbeing in the same year koopman et al develop the prehit instrument to assess ehealth literacy first they use focus groups to test the questionary then conduct a survey and collect 195 responses from the patients with chronic conditions ages between 20 and 86 finally based on factor analysis authors extract eight strong factors the need for health information experience in using computer and internet fear of computers relationship with a physician experience in using cellphone concerns about privacy on the internet and a need to avoid undesirable information we also need to mention dual instruments for the assessment of ehealth literacy based on the metaanalysis by karnoe kaysen lin et al study of computer and health literacy and skills with chinese patients the authors use chew bradley and boyko questions regarding health literacy and generated computer literacy questions the results show that 436 of respondents have a low level of health literacy and even 967 have a low level of computer literacy taha sharit czaja explore correlation between numeracy ability technology skills and health literacy they generate questions regarding habits in using cell phones computers and atms and test of functional health literacy in adults together with questionary for analysis of specific portals use also the authors use selfassessment for webuse skills they found an inconsistency between numeracy skills and health literacy while numeracy and internet skills impact task performance without going into details reininger et al and van der vaart drossaert taal van de laar also gave their contribution on the topic 2018 conduct a research study among adolescents using eheals literacy scale for the first time in serbia based on the sample of 702 respondents the authors conclude that adolescents have an aboveaverage selfconfidence level in searching and using information from the internet they can assess the quality of available health information but struggle to find the source of information although female students show more confidence in this area multiply regression found that the female gender also has a higher level of ehealth literacy gazibara et al methodology and data in the previous section we discussed the fullscope methodological approach to appraise ehealth literacy however such approach requires collection of primary data through specially designed survey which goes beyond the scope of our research resources therefore we rely on the existing sets of secondary data on digital skills and subsequently reduced scope of ehealth literacy examination to several ehealth skills covered in available datasets this papers methodology is based on the eurostat comprehensive survey on digital skills usage of information and communication technologies in households and by individuals which is annually conducted by the national statistical institutes of eu member and candidate countries the eurostat survey covers a broad list of ict subjects including ict competence and skills and the use of the internet and other electronic networks for different purposes by individuals andor households following the acceleration diffusion and expansion of the ict usage the questionnaires list of questions has varied over time so that questions related to the ehealth skills only recently were added therefore our methodology consists of two building blocks 1 identification of ehealth skills and women entrepreneurs we use the 2018 survey conducted by the serbian statistical office wherein we identified three questions related to the ehealth skills which of the following activities have you performed over the internet in the last 3 months which of the following goods or services have you ordered on the internet in the last 12 months which of the following activities have you performed over the internet for private purposes in the last 3 months in the second step we use sociodemographic characteristics of the survey participants to render the subsample of female entrepreneurs in particular we combine the criterion of selfemployment with the female gender to select proper cases 2 statistical analysis of the data it covers the following set of analytical issues comparison of ehealth skills visàvis comparable digital skills of the female entrepreneurs inference on differences in the level of ehealth skills between male and female entrepreneurs as well as between female entrepreneurs and other women inference on associations between ehealth skills and sociodemographic characteristics of the women entrepreneurs the full 2018 sample from the survey on ict usage in households and serbia individuals includes 2652 participants among them we identified 48 participants that jointly match both gender and selfemployment criteria to render a subsample of the women entrepreneurs we consider the following sociodemographic characteristics age education number of kids size of the average monthly income and settlement type choice of sociodemographic characteristics illustrated in table 1 is aligned with motives to examine their associations with ehealth skills the sociodemographic characteristics distribution reveals that the average woman entrepreneur in serbia is aged between 4655 years secondary educated have no infant or adolescent children earns less than 600 eur and lives in an urban area results and discussion in 2015 the dg connect and the eurostat information society working group developed a comprehensive digital skills indicator to measure the extent of digital competence in europe based on the set of individual indicators derived from the survey on ict usage those indicators basically cover the following area of digital skills information communication problem solving and familiarity with online services regarding the nature of three identified questions related to ehealth seeking health information can be considered an information skill whereas buying pharmaceutical products and scheduling appointments online or using applications belongs to a group of familiarity with online services skills for the purpose of research we picked several peer skills from the respective groups to provide a comparative analysis subsequently we rendered the variables that indicate the participants ability to perform some of those skills the crosstabulated distribution of digital skills across female and male entrepreneurs and other women is presented in table 2 table 2 comparisons of ehealth and peer digital skills between women entrepreneurs and other population groups in serbia source authors calculations comparative analysis of digital skills reveals that abilities to perform information skills exceed familiarity with online services regardless of the population group when only ehealth skills of female entrepreneurs are considered seeking healthrelated information is the most frequently exhibited skill whereas scheduling medical appointments appears as the least commonly practiced skill not only among ehealth but also among all digital skills considered it is a quite expected result since the scheduling of the medical appointments online or using web applications is the relatively new eservice in serbia relative to internet banking or online purchasing and therefore still underdeveloped a comparison of digital skills between female entrepreneurs and other women reveals several important insights female entrepreneurs are more digitally skilled than other women regardless of the type of skill considered this is especially the case in a group of informational skills where all differences in proportions are twodigit numbers and the ztest of proportions confirms the significance of those differences however the difference between the share of women entrepreneurs visàvis other women seeking health information online is the smallest one among information skills the opposite case is on the side of familiarity with online services whereby the difference in purchasing of pharmaceutical products online between female entrepreneurs and other women is the secondhighest the only difference that is higher is recorded for the online selling in line with expectations that such activity is not typically performed by the women who are not selfemployed when differences in digital skills between female and male entrepreneurs are compared ehealth skills particularly seeking healthrelated information and purchasing the pharmaceutical products online appear to be the only which are statistically significant the equality of digital skills between female and male entrepreneurs is an interesting finding that opposed evidence from previous research which shows that serbias digital skills are gendersensitive the second part of the empirical analysis covers association between sociodemographic variables and ehealth skills to this end we computed the crosstabulations of sociodemographic variables and ehealth indicators and ran the pearson chisquared test of association the selection of the sociodemographic characteristics is based on the prior expectation about possible associations with ehealth variables which are grounded on the following rationales age and education the previous research on digital skills and the digital divide figured robust empirical evidence that age and education are associated with digital skills in particular mastering digital skills is inversely related to age and proportional to education level the number of kids while this characteristic is not typically encompassed in the research on digital skills it is reasonable to assume that care about infants or adolescents is timeconsuming and therefore may motivate selfemployed women to increase involvement in online activities average monthly income the existing literature profoundly documents evidence that stronger skills provide workers with better opportunities for jobs and higher income therefore income level and level of digital skills should covary in the same direction settlement type despite coverage of broadband connections in the last couple of years has considerably improved in suburban and rural areas in serbia the population living in the urban areas still has better access to ict means and therefore it is arguably to assume that the urban population is more digitally skilled regarding the frequency distribution of the sociodemographic characteristics of participants in the sample we did several modifications to make this distribution more even by merging modalities with an insufficient number of observations i age categories 2535 and 3545 ii 2 or more children iii primary and secondary education vocational and academic education analysis of the association between sociodemographic characteristics and ehealth skill seeking healthrelated information of female entrepreneurs is shown in table 3a the results of the chisquared tests do not confirm expectations about the existence of those associations indeed proportions between female entrepreneurs who search healthrelated information online and those who are not quite evenly distributed across modalities of sociodemographic characteristics without sizable deviations may indicate associations existence on the other side analysis of the association between sociodemographic characteristics and ehealth skill scheduling medical appointments online or via applications reveals the existence of such associations for two variables education and average monthly income values of the ratios that read in table 3b confirm expected positive associations the proportion of tertiary educated female entrepreneurs who made online scheduling of appointments considerably exceeds the proportion of nontertiary educated and the same holds for earnings over 600 eur the previous finding is also confirmed in the case of ehealth skill online purchase of pharmaceutical products as reads in table 3c this skill is associated both with education and the average monthly income of female entrepreneurs association is also found in case of settlement type the proportion of female entrepreneurs that purchase pharmaceutical products in urban areas exceed those in suburban or rural areas this is not a surprising result bearing in mind that online purchasing also requires delivery services which are better developed and infrastructurally supported in urban areas conclusion the covid19 pandemic becomes a great challenge for citizens but also health systems and health authorities globally in many countries the systems cannot meet all patients needs or people do not want to visit medical facilities out of fear digital health care in the broadest sense is one way to alleviate these problems however in order for such a system to be effective it is necessary for users to have a certain level of knowledge about health and treatment as well as digital skills users with a higher level of knowledge and skills have a better opportunity to use information from the world wide web online and offline communication with medical staff or ordering drugs and similar preparations via the internet in this paper we analyze to what extent female entrepreneurs in serbia utilize ehealth opportunities and whether this utilization is associated with selected sociodemographic variables we focus on the three particular ehealth skills covered by the survey on serbias ict usage for 2018 seeking healthrelated information online scheduling medical appointments online or via applications and online purchase of pharmaceutical products the first one considered ehealth skills are regarded as an information skill whereas the second and third are regarded as familiarity with online services besides ehealth skills we also include peer information skills and familiarity with online services in analysis for the purpose of comparison the analysis results confirm the presumption that female entrepreneurs have mastered digital skills better than other women including ehealth skills when female and male entrepreneurs are compared seeking healthrelated information and purchasing pharmaceutical products appears as the ehealth skills more frequently utilized by female entrepreneurs bearing in mind how skills are assessed such result does not necessary means that women entrepreneurs are more capable of seeking healthrelated information and purchasing pharmaceutical products there is also a chance that women in general are more concerned about health than men apart from those two ehealth skills other digital skills are evenly utilized by both female and male entrepreneurs opposite to the previous research findings that digital literacy in serbia is gendersensitive the association between female entrepreneurs sociodemographic characteristics and utilization of ehealth skills is not confirmed in most cases the notable exceptions are statistically confirmed associations of education level and average monthly income with ehealth skills related to familiarity with online services we did not consider the direction of causality of those associations nevertheless it is reasonable to assume that the education level increases the level of digital skills while a higher level of digital skills increases the prospective for higher earnings the research has several shortcomings besides the already mentioned limitation that ehealth indicators basically reflect actual performances rather than skill capabilities other important concern is the insufficient representativeness of the female entrepreneurs in the sample additionally an item from the survey on ict usage related to scheduling appointments with practitioners online is used as a proxy for scheduling medical appointments similarly eurostats definition of selfemployment predominantly covers entrepreneurs but not exclusively therefore further research on this topic should secure a larger and more representative sample of the female entrepreneurs and increase ehealth skills coverage up to the fullscope measurement of ehealth literacy

this papers main objective is to assess the current level of ehealth skills of female entrepreneurs in serbia and their respective associations with selected sociodemographic characteristics to this end we use a dataset from the 2018 survey on ict usage in serbia in particular the analysis covers three ehealth skills seeking healthrelated information online scheduling medical appointments online or via applications and online purchase of pharmaceutical products the analysis shows that female entrepreneurs in serbia on average utilized ehealth opportunities more frequently than other women or male entrepreneurs level of education and average monthly income appears as the sociodemographic characteristics associated with ehealth skills related to familiarity with online services

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introduction marriage for muslims is one of the many sunnahs taught by rosulullah saw the law of marriage can vary in its situation and conditions actually a marriage is carried out certainly because of a noble purpose if in the quran it is stated that the purpose of the implementation of marriage is an effort to form a family that is sakinah mawaddah and warahmah in the provisions of laws and regulations especially law number 1 of 1974 it is mentioned that the definition and purpose of marriage are contained in article 1 and chapter 1 which reads marriage is the inner birth bond between a man and a woman as husband and wife with the aim of forming a happy and eternal home family based on the one true godhead it is very clear that the purpose of marriage is merely to achieve the value and theological pleasure of the creator in fact a marriage is carried out once in a lifetime because marriage is based on a noble purpose but in reality on the ground not a few marriages are carried out not on the basis of noble goals or even vice versa because of other purposes that are not desired by allah swt as a result of marriages that are carried out without a noble purpose there are many decisions or termination of a marriage called divorce quoting a statement from the director general of bimas islam kamaruddin amin that the divorce rate in indonesia continues to experience a drastic spike and continues to increase this is based on data owned by the director general of binmas islam 2 per year 2015 the divorce rate in indonesia reached 394246 cases then in 2016 it increased by 401717 cases in the following year 2017 continued to increase to 415510 cases then in 2018 it again jumped to 444358 cases meanwhile in 2020 only until august the divorce rate has reached 306688 cases the high number of divorces on a national scale in indonesia which continues to increase from year to year is a crucial problem that must get special and serious attention as in fahmi ihsan margolangs article which explains the causes of divorce quoted by research from turkey that women who experience domestic violence to divorce one of the factors is the low level of education 1 both for men and women therefore knowledge of marriage is needed for every couple who will hold a marriage so that couples who plan to hold a marriage can prepare well and can create a household that is sakinah mawadah and warohmah 1 coordinating minister for human empowerment and culture muhajir efendi expects kua and related ministries to provide comprehensive premarital guidance from aspects of religion health to child nutrition the ministry of religious affairs through the decree of the director general of islamic community guidance number 373 of 2017 concerning technical guidelines for marriage guidance for bridestobe determines that the implementation of premarital education can be carried out by agenciesinstitutions outside government institutions other than kua 2 this premarital education can be carried out by islamic religious organizations that have fulfilled the provisions set by the government 3 the above provisions of the director general provide extensive opportunities for the community to participate widely in family development and development and reduce the divorce rate in the household 4 so the responsibility in implementing premarital education is not only the government but it is the responsibility of the community to work together to improve a happy and prosperous family based on the background above researchers were moved to study and identify the problem of the high number perceraian in an understanding and study researchers assume that the main factor is caused by the low understanding and knowledge possessed by prospective spouses or marriage partners resulting in several things such as ignorance the role and function of each in the household west science social and humanities studies  327 vol 01 no 12 december 2023 pp 325335 and so on therefore through this research opportunity researchers are trying to prove premarital education as the most important thing as a solution in improving problems related to the continuity of marriage one of which is the divorce rate literature review marriage marriage is an institution that contains multifaceted and multidimensional the diversity of aspects contained in this institution runs throughout the age of marriage itself the aspect itself looks relatively evenly distributed one does not dominate the other aspect 5 these aspects as we already know are personal aspects social aspects ritual aspects moral aspects and cultural aspects the diversity of aspects contained in the institution is a sign that the holy communion is a sharia of high degree and noble value such is the importance of this institution placing marriage in a central and strategic position in the family system according to islam 6 marriage is a living communion between a man and a woman formally confirmed by law that is juridical and mostly also religious according to the purpose of the husband and wife and the law and is carried out for the duration of his life according to the institution of marriage 3 in the civil code the definition of marriage is not expressly regulated by provisions such as article 26 which views marriage only in civil relations and article 27 that marriage adheres to the principle of monogamy article 13 states that husbands and wives must be faithful to each other please help and help help although there is no definition of marriage legal science seeks to define marriage as a bond between a man and a woman that is recognized as valid by state legislation and aims to create an eternal family according to marriage law number 1 of 1974 article 1 paragraph 2 marriage is defined as the inner birth bond between a man and a woman as husband and wife with the aim of forming a family a happy and eternal home based on the one and only godhead the inclusion based on the supreme god is because the indonesian state is based on the first pancasila precept is the supreme godhead until here it is firmly stated that marriage has a very close relationship with religion spirituality so that marriage not only has an externalphysical element but also has a mentalspiritual element 7 according to etymology jurisprudence scholars define marriage in the context of biological relationships below will be explained the definition of marriage according to para ulama fiqh as follows 1 imam shafii means the understanding of marriage is a contract with which it becomes lawful sexual relations between men and women while according to the meaning of majazi marriage means sexual relations 2 hanafiah marriage is a contract that gives the benefit to perform mutah intentionally means that it is lawful for a man to have istimta with a woman as long as there are no factors that prevent the validity of the marriage sharia 3 hanabilah nikah is a contract that uses lafaz inkah which means tajweed with the intention of taking benefits for fun 4 almalibari defines marriage as an akad that contains the ability to have intercourse using the word nikah or tazwij 5 muhammad abu zahrah in his book alahwal alsyakhsiyyah defines marriage as a contract that causes legal consequences in the form of lawful intercourse between a man and a woman mutual help and raises rights and obligations between the two in indonesia a contract or agreement is called a marriage contract as an agreement or contract the parties related to the agreement west science social and humanities studies  328 vol 01 no 12 december 2023 pp 325335 or contract promise to build a happy home born inwardly by giving birth to children and grandchildren who carry forward their ideals if the bond of birth and mind can no longer be realized in marriage for example no longer able to have sexual relations or unable to bear offspring or each already has a different purpose then the agreement can be canceled through termination of marriage or at least reviewed through remarriage after divorce from the above opinion the definition of marriage in jurisprudence can be concluded to give the impression that women are placed as objects of pleasure for the man what women see is only the biological aspect this is seen in the use of the word alwat or alistimta which all connote sex indonesian marriage law experts also provide definitions of marriage among others according to 1 according to wirjono prodjodikoro 4 marriage is a regulation used to regulate marriage this is what gives rise to the understanding of marriage 2 according to sajuti talib marriage is a sacred and broad and solid covenant to live together legally between a man and a woman to form an eternal courteous loving peaceful and happy family 3 according to prof ibrahim hosen marriage according to the original meaning of the word can also mean a contract with him to be lawful genitalia between a man and a woman while according to other meanings intercourse 4 according to subekti marriage is a legal relationship between a man and a woman for a long time in general the quran only uses these 2 words to describe the occurrence of conjugal relations legally these words have legal implications in relation to ijab kabul ijab kabul marriage is essentially a pledge from the prospective wife through her guardian and from the prospective husband to live in harmony in order to realize the sakinah family by carrying out all the guidance of religious teachings and carrying out all obligations as a husband in article 1 of the 1974 marriage law on marriage the definition of marriage is formulated in which the purpose and basis of marriage are contained with the formulation marriage is an inner birth bond between a man and a woman as husband and wife with the aim of forming a happy and eternal family based on god almighty if you look at the first part of the article marriage is an inner birth bond between a man with a woman as husband and wife from the above sentence it is clear that marriage only exists when it is carried out by a man with a woman along with the development of the times often found in society there is a relationship between a man and a man called homo sexual or a woman with a woman called lesbian this relationship cannot be continued to the level of marriage because in the state of indonesia does not regulate samesex marriage and in religious law there is no samesex marriage allowed divorce indonesias positive law law number 1 of 1974 concerning marriage uses the principle of making it difficult for divorce to occur 8 this is evidenced by the provision that divorce can only be carried out before a court hearing after the court concerned has tried and failed to reconcile both parties the courts referred to in this case are the district court for those who are religious other than islam and the religious court for those who are muslim as mentioned in uu no7 of 1989 juncto law no 3 year 2 6 concerning religious courts in article 2 that religious courts have the duty and authority to examine decide and settle cases in the first instance between persons of muslim faith one of whose authorities is in the field of marriage the marriage law adheres to the principle of making it difficult for divorce to occur because divorce will bring bad consequences for the parties concerned with the intention of making it difficult for divorce to occur it was determined that having a divorce there must be enough reason for the husband and wife will not be able to live in harmony as husband and wife divorce is also part of marriage because there is no divorce without marriage starting marriage is the beginning of cohabitation between a man and a woman as stipulated in applicable laws and regulations in all legal traditions whether civil law common law or islamic law marriage is a private contract between a man and a woman to live as a married couple based on the willingness of both parties marriage is seen as the basis for the family unit which has an important significance in the moral or moral preservation of societyand the formation of civilization marriage as a covenant or contract then the parties who are bound by the agreement or contract promise to build a happy home born inwardly by giving birth to children and grandchildren who continue their ideals if the birth bond cannot be realized in marriage for example no longer able to have sexual relations or unable to bear children or each already has a different purpose then the agreement can be canceled through termination of marriage or at least reviewed through remarriage after divorce according to a survey conducted by national fatherhood asking people the most common reason their marriages are untenable is a lack of commitment keeping a commitment that has been set together is one of the keys to a successful marriage when one party cannot keep the mutually agreed commitment it will result in separation as for the factors caused bytoo many quarrels the survey also stated that quarrels oftendo not lead to quarrels then infidelity indeed no one likes to be pitted in a relationship especially in marriage because marriage is too early age can be a factor in the dissolution of a marriage 6 according to the centers for disease control and prevention nearly half of teen marriages fail within the first fifteen years that number drops to 35 percent for couples who marry in their midtwenties then also because it is not in accordance with expectations and the absence of balance and equality there are also factors of lack of preparation and factors of domestic violence premarital education education is an important component that becomes the foundation in any aspect in the sense that education is distinguished in a broad sense and a narrow sense by george f kneller education is broadly defined as a persons actions and experiences that can affect his mental physical and physical abilities while narrowly it is defined as the transformation of knowledge values and skills between generations inherited by the community through formal and nonformal education 9 education is a conscious and planned effort to create a learning atmosphere and learning process so that students actively develop their potential to have religious spiritual strength selfcontrol personality intelligence noble character and skills needed by themselves and society 10 education includes the teaching of specific skills as well as something that cannot be seen but is more profound namely the provision of knowledge consideration and wisdom one of the main foundations of education is to teach culture through generations 11 furthermore regarding premarriage which comes from two syllables namely pre and nikah pre here means before or beginning while marriage is defined as the process of marriage as the understanding has been outlined in law no 1 of 1974 concerning marriage so the meaning of premarriage is a situation when the couple who will hold the marriage is still a bride or couple 12 premarital education can be interpreted as an effort to transform knowledge and values and skills of a science related to the understanding ways and objectives of household management that will later be felt by the prospective couple or bride so that they are able to achieve the level of stability and understanding of household science this premarital education has a very important material content in its implementation these materials contain knowledge about household preparation west science social and humanities studies  330 vol 01 no 12 december 2023 pp 325335 including how to choose a prospective partner then the substance and proper procedures regarding marriage there is also the concept of building a family communication patterns of the bride and groom and how to manage a good household from fostering a wife to educating children methods this type of research is qualitative namely the amount of data needed is in the form of description perception argumentation and opinion of the research object itself data collection techniques in this study use literature techniques namely all efforts made by researchers to collect information relevant to the topic or problem being studied the information can be received from books related to the issue of the implementation of the governors regulation and violations of the apparatus code of ethics research reports regulations statutes and written sources both printed and other online sources in this study researchers conducted research with content analysis methods namely methodologies that utilize a set of procedures to draw correct conclusions from a document results and discussion implementation of premarital education premarital education which is carried out as an effort to provide education to prospective married couples is a preventive program to create a harmonious family in accordance with the theory of marriage which states that marriage is a step to unite two individuals to live institutionally together tosustain each others life and life as one of the basic importance of implementing premarital education we can see in the following table based on the table above we can see how the increase in divorce rates from 20192020 in bandung city increased by 4713 serang regency experienced an increase of 289 and in east jakarta experienced an increase of 35 cases recorded in the local population and civil registration office as a sample representing various provinces we can observe together in divorce cases not decreasing but increasing a marriage intention based on a noble goal should have a better impact in pursuing and living a domestic life for the indonesian nation which is an important content in the implementation of premarital education activities is that the bride and groom will get guidance and also good provision to support family life in addition in its implementation premarital education participants are given materials to support preparation starting from determining the choice of candidates to how they will be when living a married life armed with knowledge about the procedures for living a domestic life at least the bride and groom when entering the marriage stage will not be surprised by some events that they have never encountered before the basis for the implementation of premarital education is based on the regulation of the director general of islamic community guidance number dj ii 542 of 2013 concerning guidelines for the implementation of premarital courses the regulation which contains as many as vi west science social and humanities studies  332 vol 01 no 12 december 2023 pp 325335 chapter and 9 of this article only talks about the technical implementation of premarital education in this case it is not expressly regulated about the necessity to attend premarital education for prospective brides and grooms who want to hold a wedding moreover making a certificate of completion of premarital education as one of the mandatory requirements in registering a marriage certificate based on the results of a survey conducted by the research team of the three regions that became research samples they had uniformity in the implementation of premarital education considered not optimal usually the implementation of premarital education is carried out at kua on wednesdays every 0900 1200 likewise the pandemic situation which makes everything meet limitations has an impact on premarital education services in addition existing regulations have not been able to provide space for firmness regarding the obligation to attend premarital education for the bride and groom supporting and inhibiting factors the implementation of premarital guidance for bridestobe in west java dki jakarta and banten cannot be separated from supporting and inhibiting factors similarly premarital guidance programs in west java dki jakarta and banten the supporting factors for premarital coaching include the enthusiasm of participants competent mentors and very simple delivery methods while inhibiting factors include inadequate facilities and infrastructure incomplete guidance material and very short guidance time premarital guidance program at the office of religious affairs in west java dki jakarta and banten regions in the implementation of this premarriage program activity of course there are several factors that become obstacles and drivers in the implementation of the activity as well as the supporting factors are participants who are enthusiastic in participating in the program then the supervisor is competent enough and masters the science of marriage and besides that the supporting factors of the material presented are quite simple so that the participants can understand well however in this implementation there are also inhibiting factors in the realization of the program namely inadequate infrastructure facilities lack of facilities that hinder the realization of the program then also the unattractiveness of the event concept so that the participants feel bored in the activity in addition to that factor also the distance of the bride and groom from the event venue which is relatively far from the location besides that there are also weak regulations which is not expressly intended to emphasize the compulsory activities of this program becomes optional only causes and effects of divorce divorce is the rupture of the relationship between husband and wife which has an impact on the breakup of a family divorce can occur due to various domestic problems that arise in the family the problem can be due to many factors these factors are present as a result of the incomprehension and unpreparedness of married couples in order to navigate the household due to the lack of understanding and knowledge about marriage material to support a sakinah household mawaddah warahmah based on the results of the study showed that the factors causing spousal divorce that occurred in the subjects in this study were a family disharmony this occurs due to ego or uncontrollable emotions that have an impact on harmony and not infrequently quarrels occur to cause domestic violence b infidelity is a factor inherent in a persons psyche of uncontrolled desires that have an impact on attraction to other partners in the review of behaviorism theory this is a fulfillment of high desires and is not accompanied by good emotional control abilities so that in the end it has an impact on the existing alignment aspect this is as stated that one of the causes of divorce between parents is a third party or infidelity not only cases of infidelity divorce can also be caused by economic factors and disharmony in the family another causative factor is the disharmonious behavior of parents in the family thus making household relationships towards marriage based on this after the divorce their parents decided to entrust their children to orphanages for various reasons the results of this study can reveal that divorce occurs because it is influenced by several factors that have been mentioned above parents should have a protective role tasked with meeting the needs of children cultivating basic social rules and teaching the process of early socialization in society if the role of parents is neglected then children will have difficulty in socializing in society therefore parents must understand each others roles and support each other so as to minimize divorce and can support the development of children in the future conclusion based on the explanation above researchers concluded that premarital education that is carried out is very important to be carried out as an effort to provide education to prospective married couples as a preventive program to create a harmonious family in accordance with the theory of marriage which states that marriage is a step to unite two individuals to live institutionally together to sustain each others lives and lives in its implementation premarital education participants are given materials to support preparation starting from determining the choice of candidates to how they will be when living a married life the implementation of premarital education in several kua is considered still not optimal for two reasons namely the pandemic situation and the lack of regulatory firmness then the supporting and inhibiting factors in this activity are supporting factors of premarital coaching include the enthusiasm of participants competent mentors and very simple delivery methods meanwhile inhibiting factors include inadequate facilities and infrastructure incomplete guidance materials very short guidance time and the absence of strict regulations governing premarital education then the cause of divorce stems from unpreparedness and lack of understanding of household knowledge possessed by married couples ultimately causing disharmony in family relationships infidelity or the presence of a third person economic problems and communication problems that are not well established so that it has an impact on child development disharmony between both large families and others

this study aims to examine the urgency of premarital education as a preventive effort in reducing divorce rates in west java dki jakarta and banten the research method used is the literature review method which involves an indepth analysis of various relevant literature sources the results showed that premarital education has a crucial role in preparing prospective couples to face the challenges of married life through a deep understanding of values effective communication and conflict resolution skills couples can build a solid foundation for a sustainable marriage relationship this study also identified various supporting and inhibiting factors for the implementation of premarital education in the region these findings provide valuable insights for the development of premarital education programs that are more effective and can be widely adopted in the community the implications of this research can help the government educational institutions and related parties to design policies that support improving the quality of marriage relationships and reducing divorce rates in society

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introduction in western countries immigrants tend to have lower occupational statuses and smaller incomes than native workers a wellknown explanation for the economic disadvantage faced by immigrants concentrates on human capital this theory stipulates that immigrants are less skilled and less productive than are natives because many immigrants come from lessdeveloped countries they are often less educated than the nativeborn population furthermore immigrants cannot rely on their human capital as natives do because the skills they gained in their countries of origin may be of lower quality and are often more difficult to transfer in addition employers are uncertain about these specific skills as the length of stay in the host country increases however immigrants tend to improve their economic outcomes an explanation for this economic mobility is that immigrants acquire the hostcountry language and skills that allow them to compete more effectively in the hostcountry labor market there is ample support in the literature for the notion that immigrants who acquire proficiency in the hostcountry language significantly improve their economic opportunities similarly research has shown that acquiring hostcountry credentials and labor market experience facilitates the economic integration of immigrants another important explanation for immigrants economic disadvantage focuses on social capital upon arrival in the host country immigrants benefit from relationships with coethnic family and friends these contacts provide them with knowledge information and other essential skills including how to search for a job and how to behave on the job these skills in turn facilitate the immigrants adjustment to the labor market several studies have shown that having coethnic family and friends in the hostcountry facilitates the economic integration of immigrants in particular by providing assistance in finding a job and higher earnings an influential hypothesis in the scholarly literature on social capital states that contacts with natives are even more beneficial for immigrant economic outcomes than coethnic contacts relationships with natives can provide access to the host society by facilitating social and cultural adaptation and providing broader job choices in this way contacts with natives are a form of bridging social capital that is crucial for providing access to external resources and for the diffusion of information whereas contacts with coethnics are a form of bonding social capital that is most useful for strengthening solidarity and reciprocal relationships although several studies have examined the relationship between bridging social contacts and immigrant economic outcomes most prior research has relied on crosssectional data which makes it difficult to infer the causal effects of bridging social contacts in these studies a positive correlation between immigrants social contacts and economic outcomes is interpreted as evidence of the effect of social contacts however because higher occupational status andor income provide people with more resources to meet and interact with others the positive correlation between social contacts and immigrants economic outcomes may reflect reverse causality the tendency of people with better economic outcomes to have more friends the positive correlation between social contacts and economic outcomes for immigrants may also be spurious merely reflecting the fact that people with similar backgrounds tend to associate with one another the problem of social homophily has been recently addressed in two studies on immigrants in germany kanas et al estimated a fixedeffects model and found that even after taking into account a possible bias caused by social homophily immigrants who have social contacts with germans are more likely to be employed as compared to those without such contacts based also on the fixed effects model kalter showed that having german friends increases the occupational status of secondgeneration turkish immigrants this paper attempts to build on this scholarship by studying the occupational status and annual income of immigrants to germany it contributes to the literature in three ways first we focus not only on the impact of social contacts with coethnics but also on social contacts with natives there is a longstanding tradition of research on the impact of ethnic enclaves on immigrant economic incorporation however mostly due to the limitations of the available data few studies have analyzed the impact of contacts with natives on the economic outcomes of immigrants our second contribution is that we use longitudinal data that enables us to test the causal effect of social contacts more rigorously the german socioeconomic panel is a comprehensive dataset that offers information on immigrant social contacts with family friends and neighbors contacts with germans volunteering and immigrants economic performance over a twentyyear period we also have additional information about the percentage of coethnics in the immigrants region of residence from the german microcensus we examine the influence of social contacts on immigrants occupational status and annual income occupational status and income may be viewed as two measures of the same immeasurable variable of interest labor market outcome although economists have often expressed concern over immigrants earnings and sociologists have mused over the occupational status of immigrants the extant literature rarely addresses both outcomes conjointly by studying both occupational status and income simultaneously we provide more insight into the role of social contacts in immigrants economic progress which occurs not only among occupations but also within them although the occupational status and income are estimated separately it should be noted that occupation can be also considered as an intervening variable between educationlanguage proficiency and income that is education and language skills can have both direct and indirect effects on immigrants income where indirect effects operate via occupational attainment there are several reasons why we do not include the occupational status in the income equation however first in the literature occupation is typically viewed as an aggregated variant of the income variable and so using it as an independent variable in the income equation is considered illegitimate as cited in sloane second the assumption that people get their occupational status first and then earn the income may be in our view problematic as people are likely to make decisions about the two things simultaneously third what is even more important reason for us is that the occupational status is only observed among employed immigrants and so it cannot be included in the selection equation of our heckman model third we contribute to the literature by studying interactions between social contacts and originand hostcountry human capital more specifically we ask whether ethnic concentration in a region of residence affects the economic returns to originand hostcountry human capital assuming that coethnic regional concentration increases the transferability of origincountry specific human capital and reduces the uncertainty of employers towards origincountry skills the lack of hostcountry specific human capital can be less important in regions with high concentrations of coethnics than it would be in regions with fewer coethnics this would suggest that immigrants living among coethnics will benefit more from their origincountry human capital but at the same time they will receive comparatively lower returns to hostcountry human capital than do those living in regions with fewer coethnics theory and hypotheses social contacts according to social capital theory social contacts facilitate economic opportunities because they make accessible to people the resources of others most notably knowledge information and influence immigrants benefit from their social contacts by obtaining information specific to the host country and assistance in the labor market including vital facts and advice about where to look for a job what the available jobs are how to present themselves to employers and how to behave on the job the most immediate sources of social contacts for immigrants are coethnic family and friends already living in the hostcountry immigrants also acquire their social contacts through leisure activities such as volunteer work and from neighborhood and job acquaintances living among many coethnics is not only important for immigrants because it facilitates access to lower cost ethnic goods and services including ethnic foods clothing and coethnic contacts but also facilitates their economic outcomes by allowing communication in the immigrants native language and providing assistance in the hostcountry labor market this leads us to hypothesize that the more social contacts immigrants have the higher the occupational status and annual income of immigrants the extant literature suggests that the quality of the resources of the contact person affects the quality of the job that is found via this person it follows that people who obtained a job through a person with a higher occupational status find higher status jobs than those who were helped by a person with lower occupational status it can be argued that at the host country labor market knowledge and information provided by natives may be superior to those provided by coethnics natives are better informed about specific job openings they know more about how to find jobs and they know more about how to present themselves to employers than do nonnatives one reason for this difference in resources is that natives have more exposure to the domestic labor market through their own experiences and those of their parents than do immigrants another reason is that typically natives are less often unemployed are more highly educated and have more prestigious jobs than immigrants furthermore several studies in the literature on the nativeborn population suggested that social contacts whose social networks extend far beyond ones own network are more valuable in the labor market than social contacts whose social network overlaps with ones own network for example burt suggested that being connected to different social networks which are otherwise disconnected by structural holes provides advantages in access to different sources of information which are more additive than overlapping a similar conclusion was reached by putnam who suggested that although bonding social capital which connects socially homogenous people by similarities in gender ethnicity and socioeconomic status is crucial for getting by bridging social capital that links socially heterogeneous people is critical in getting ahead although these studies were not concerned with immigrants they imply that contacts with natives which reach outside an immigrants own ethnic group are more helpful for finding better jobs than are coethnic contacts in this context some authors have argued that connections to coethnics might even hamper access to high status salary jobs wiley suggested that although coethnic enclaves protect immigrants by offering more secure job opportunities they also reduce the possibilities to meet and interact with natives thereby isolating immigrants from better job opportunities in the mainstream economy concurring with this argument martinovic et al showed that in the netherlands immigrants who resided in heavily coethnic areas developed significantly fewer contacts with dutch natives as compared to immigrants who lived in the regions with fewer immigrants because more lucrative jobs lie mainly outside the ethnic enclaves relying solely on ethnic ties would lead immigrants to find jobs of lower prestige and earnings based on the foregoing observations we hypothesize that immigrants who have more contacts with natives have a higher occupational status and a higher annual income than those who have fewer contacts with natives coethnic concentration and originand hostcountry human capital we also hypothesize about interactions between coethnic residential concentration and human capital more specifically we test whether living among many coethnics affects the economic returns to originand hostcountry human capital it can be argued that immigrants who live in regions with many coethnics can benefit more from their origincountry skills than do immigrants who live in the regions with few coethnics specifically coethnic concentration increases the transferability of origincountry skills by facilitating communication in the immigrants native language and harnessing knowledge and experiences specific to a particular ethnic background coethnic concentration can also reduce the uncertainty of employers by enabling employment with coethnic employers who are knowledgeable about origincountry specific credentials or by influencing native employers to become more familiar with origincountry credentials based on these arguments we hypothesize that the higher coethnic concentration in the region of residence the higher the economic returns to origincountry human capital by facilitating employment in occupations in which origincountry skills are more transferable and more highly valued by employers coethnic residential concentration can also reduce the economic returns to hostcountry human capital specifically by enabling immigrants to communicate in their native language coethnic residential concentration reduces the cost of not speaking the destination language similarly by increasing the transferability of and reducing the employers uncertainty towards credentials acquired in the immigrants country of origin residing among many coethnics reduces the costs of not having destination educational credentials or training in line with these arguments chiswick and miller showed that immigrants to the united states who live in areas where many others speak their language known as areas of high linguistic concentration are not only less proficient in english but also receive lower returns to their english language skills as compared to those who live outside areas of high linguistic concentration these arguments lead us to our fourth hypothesis that the higher the coethnic concentration in the region of residence the lower the economic returns to hostcountry human capital data and methods the data analyzed in this study are for employed foreignborn men age 20 to 60 years 1 the data are from the 19842004 german socioeconomic panel a nationally representative longitudinal survey administrated by the german economic institute diw berlin the key advantage of the gsoep is that it provides longitudinal information on immigrants social contacts including contacts with natives language skills and preand postmigration education over a twentyyear period another advantage of the gsoep is that several foreign groups namely those of turkish greek italian spanish portuguese and exyugoslavian origin are oversampled in the survey 2 the limitation of the data is that a majority of immigrants were interviewed for the first time only after they had spent a considerable amount of time in germany because most of the investments in human and social contacts take place at the arrival to the host country it could be that social contacts were more important for immigrants occupational status and income in the first years after arrival than they are now after many years spent in germany 3 for the purpose of this paper we used sample b and sample d dependent and independent variables occupational status employed respondents were asked their occupation for their current job occupational status is measured in terms of the international socioeconomic index the isei scale measures the hierarchical position of the occupation it is a set of weights assigned to occupations in such a way as to maximize the role of occupation as an intervening variable between education and income the scale ranges from 16 to 90 the mean occupational status in our sample of immigrants is 33 points which is equivalent to sewers wood treaters cabinetmakers etc trades workers and plumbers an increase of one standard deviation in the average occupational status would be equivalent to working in one of the following occupations social work associated professionals production clerks and salespersons a decrease of one standard deviation would be equivalent to working in such occupations as handpackers and other manufacturing laborers semiskilled workers bleaching dyeing and cleaningmachine operators annual income respondents reported their annual individual income this includes income from all employment including training primary and secondary jobs and selfemployment plus income from bonuses overtime and profitsharing in all waves the income variable is reported in euros in the analysis the natural logarithm of annual income is used to account for the positive skewness of the annual income variable the heteroscedasticity of income and to facilitate the interpretation of the coefficients this is a standard procedure in the analysis of income and earnings we include measures of general social contact as well as measures of bridging and bonding social contact as a measure of general social contact we use two variables frequency of contacts respondents were asked how frequently they spent time with their friends relatives and neighbors the possible answers were never occasionally and oftenregularly because categorical specification did not improve the model fit significantly we treated frequency of social contacts as a continuous variable volunteering activity respondents were asked whether they volunteered for any clubs associations or social services during the last year the possible answers were weekly monthly less frequently and never only a few people volunteered at all during the last year therefore we recoded this variable into a dichotomous variable with a score 1 for those respondents who volunteered at least once during the last year as a measure of bridging social contacts we include contacts with germans respondents were asked whether they had made close german friends since they lived in germany whether in the last 12 months they had visited germans in their homes and whether in the last 12 months they received german visitors in their homes the possible answers to all these questions were yes and no answers to these questions are highly correlated and we therefore combined them by adding up the scores on the three items and dividing them by three as a measure of bonding versus bridging social contacts we use two variables partner respondents were asked whether they were married or cohabitating and about the partners country of birth we constructed a variable with three categories 1 single 2 ethnic partner 3 german partner ethnic concentration in the region of residence measured by the percentage of coethnics in 1996 residing in nine federal states and two german cities in west germany where the respondents live 4 we assume that coethnic regional concentration increases the opportunities to meet and interact with coethnics and at the same it reduces the chances to make contacts with natives the opportunities for contacts with coethnics and germans could be measured more accurately at the labor market level than at the level of a federal state unfortunately there is no information about respondents labor market or neighborhood in the public use file of the gsoep survey additional measures of bonding and bridging contacts including their number diversity and resources would have been preferable at the same time however there are few studies that have longitudinal information about immigrants social contacts and in particular about social contacts with natives we include several measures of human capital hostcountry human capital is measured by two indicators education in germany respondents were asked about the highest degree taken in secondary school as well as for completed vocational and postsecondary training respondents were also asked whether they received their education in germany based on the highest level of obtained education in germany we constructed a variable measuring years of education in germany german language skills respondents were asked how well they speak the german language the possible answers were do not speak german at all speak german poorly speak german fairly speak german well speak german very well we treat german language skills as a continuous variable human capital from the country of origin is measured directly by one indicator education abroad the information on schooling in the country of origin was rather limited the possible answers in the questionnaire were less than compulsory more than compulsory and higher schooling information about training in the country of origin is more detailed none some instruction onthejob formal apprenticeship vocational school university and other based on the highest level of acquired education in the country of origin we constructed a variable measuring years of education abroad to understand how education abroad and education in germany are measured consider an example an immigrant who first obtained vocational diploma in turkey and then attended a vocational school in germany is assigned to have completed 10 years of education in turkey and 12 years of education in germany we also provided measures for general human capital work experience the survey provided a direct measure of work experience years from abroad and germany to control for the nonlinear relationship between work experience years and occupational status and income we also included the quadratic form of work experience several control variables were included in our model years since migration measured by the total number of years in germany weekly working hours measured by the respondents report of the average number of hours worked per week we controlled for the respondents health based on previous research suggesting the importance of health status for individual productivity and so for individual economic outcomes doctor visits respondents were asked how many times they went to the doctor in the last three months because surveys in 1985 1986 1987 and 1993 had asked the question for every specialist separately we computed the total number of doctor visits during the last 3 months we treated the doctor visit variable as a dichotomous variable with score 1 for those who visited a doctor at least once in the last three months immigrant group we distinguished between seven origin groups 1 turkish 2 greek 3 exyugoslavian 4 italian 5 spanish 6 eastern european and 7 third country immigrants we also included a set of dichotomous variables for survey year to control for contextual factors such as employment opportunities migration flows and increases in means of the annual income due to inflation method we estimate the effect of social contacts on immigrants occupational status and annual income to take into account that the occupational status and income are only estimated for immigrants who work we apply heckmans sample selection model in stata 11 heckmans sample selection model produces regression weights and standard errors that are unbiased by the selection effects one identifying variable is used in the selection equation the presence of children in the household the presence of children in the household is likely to influence adult male immigrants participation in the labor force but it is less important for their occupational status and income heckmans selection model produces the coefficient rho which indicates a correlation of the error terms of the selection equation and the outcome equation presence of children has a negative and significant effect in both selection equations and the rho coefficient is highly significant in all models suggesting that occupational status and annual income are indeed dependent on immigrants choice to work therefore we base our results on heckmans sample selection model to account for the hierarchical structure of the data ie the repeated observations of the same person over time and in community we correct for clustering at a community level a community is defined as a combination of an immigrant group and a region of residence such as turkish immigrants in berlin there are 60 communities in total in our sample 5 we use the cluster option in stata 11 to estimate robust standard errors that adjust for intracluster correlations 6 by doing this we correct the standard errors of the parameters for the dependence of the repeated observations of the same person over time and community we further study the causal relationship between human capital social contacts and the occupational status and annual income of immigrants by including in the models lagged measures of hostcountry human capital and social contacts the main insight from the literature is that immigrants with more social contacts have better economic outcomes however it can be argued that a positive correlation between social contacts and immigrants economic outcomes could also reflect the influence of economic outcomes on the frequency and composition of immigrant social contacts for instance higher status jobs may increase the opportunities to meet and socialize with natives to reduce the possibility of reverse causality between social contacts and occupational status social contact variables were measured to one year prior to the immigrants current occupational status and annual income 7 a positive correlation between bridging social contacts and occupational status or income can be also spurious due to timevarying hostcountry human capital accumulation acquiring hostcountry human capital may facilitate immigrants economic outcomes and social contacts with natives not that contacts with germans lead to higher economic outcomes for example immigrants who speak the german language and who have german educational credentials may be more likely to have higher occupational status and income and more german contacts than immigrants without these qualifications we measured hostcountry human capital variables by two years and social contact variables by one year prior to the immigrants current occupational status and income to determine whether a correlation between social contacts with germans and immigrant economic outcomes is causal or instead represents a spurious effect attributable to prior accumulation of hostcountry human capital 8 table 1 presents descriptive statistics for the independent and dependent variables table 1 about here results table 2 and 3 present the results from heckmans sample selection model predicting the effect of social contacts on immigrant occupational status and annual income each table has three models model 1 includes only measures of social contacts and controls model 2 includes measures of social contacts human capital and control variables and model 3 includes additional interaction effects between ethnic concentration in the area of residence and originand destinationcountry specific human capital we meancentered the continuous variables of german education education abroad german language skills and ethnic concentration included in model 3 because they are used to construct interaction terms and centering reduces the possibility of multicollinearity also with centering the estimated coefficients for the main effects usually refer to meaningful values rather than the meaningless score of zero on variables such as ethnic concentration education and language skills we compare the coefficients of social contacts from model 1 with those of model 2 to test whether the positive relationship between social contacts and immigrant occupational status and annual income could be spurious due to hostcountry human capital accumulation finally table 4 presents the results for the occupational status and income using sheaf coefficients the sheaf coefficient may be thought of as a latent variable that underlies several related measured indicators it is constructed as a weighted linear sum of the measured indicators such that the latent variable optimally predicts the dependent variable we constructed three sheaf coefficients general social contacts comprising of frequency of contacts and volunteering activity bridging contacts comprising of three indicators of german contacts and german partner versus singleethnic partner and hostcountry human capital comprising of german education and german language skills the advantage from using the sheaf coefficient instead of multiple indicators in the regression is that it addresses problems of multicollinearity another advantage is that it enables us to compare the relative strength of influence of created latent variables ie general social contacts versus bridging social contacts that is because each sheaf coefficient is standardized to a mean of 0 and a standard deviation of 1 different sheaf coefficients are more easily compared tables 2 and 3 about here social contacts we hypothesized that more general social contacts would enable immigrants to obtain higher occupational status and annual income we test this hypothesis by examining the effects of the frequency of social contacts volunteering activity and having a coethnic or german partner all measured prior to occupational status and income the results partially confirm this hypothesis specifically our results clearly show that volunteering in the previous year increases immigrants occupational status by 139 status points this is a small effect an increase in 139 point does not lead to any substantial change in immigrant occupational status we also find that having a german partner as compared to being single leads to a significant increase in the occupational status of immigrants contrary to our expectation however we do not find that immigrants who have an ethnic partner have higher occupational status than those who are single by a statistically insignificant 059 perhaps single immigrants interact more with germans than immigrants who are married to an ethnic partner similarly we do not find a significant positive effect of frequent contacts with friends relatives and neighbors on immigrant occupational status our results show that for each unit of increase in frequent contacts with friends relatives and neighbors in the previous year immigrant annual income rises by 5 percent moreover having a partner as compared to being single in the previous year leads to an increase in immigrants annual income we do not find that volunteering activity in the previous year leads to any increase in the annual income however thus it appears that general social contacts have more of an effect on the annual income but only a very small or no effect on the occupational status this suggests that although immigrants benefit from having general social contact which help them finding wellpaid jobs these are rarely jobs with higher occupational status we also hypothesized that immigrants who have more contacts with germans achieve higher occupational status and income in general our results support this hypothesis we find that immigrants with a german partner have a considerably higher occupational status429 status points higher and 55 percent greater annual incomethan do immigrants with an ethnic partner similarly we find evidence that having contacts with germans in the previous year increases occupational status by 294 status points and raises annual income by 32 percent finally our results show no significant relationship between a high coethnic residential concentration and immigrant occupational status and annual income 9 social contacts and originand hostcountry human capital a positive association between social contacts and immigrant occupational status and annual income could be spurious due to hostcountry human capital accumulation to test this proposition we compare model 1 which only includes social contacts variables and control variables with model 2 which includes previous measures of hostcountry human capital the model comparison shows that although the positive effect of contacts with germans decreases by more than half it still has a direct effect on immigrant occupational status similarly the strong positive effect on occupation from having a german partner versus an ethnic partner remains valid after controlling for hostcountry human capital b 429 model 1 table 2 b 261 model 2 table 2 our results suggest that the positive effect of bridging social capital on annual income is spurious owing in large part to earlier investments in hostcountry human capital specifically the positive effect from having a german as opposed to ethnic partner becomes marginally significant after accounting for previous investments in hostcountry human capital similarly the positive effect of having contacts with germans becomes insignificant in the model with hostcountry human capital variables overall we only find evidence for the direct positive effect of contacts with natives on immigrant occupational status with respect to income our results suggest that the significant effect of contacts with natives is spurious stemming instead from hostcountry human capital accumulation we have further hypothesized that a higher coethnic concentration in the region of residence produces higher economic returns to origincountry human capital as a start our results show that education abroad leads to an increase in the occupational status and annual income we also find that immigrants who obtained their education in germany have higher occupational status and annual income as compared to those who did not acquire german education 10 thus investing in hostcountry credentials provides additional human capital that improves immigrant position at the hostcountry labor market furthermore german language proficiency has a positive effect on occupational status and annual income our results also show that total number of years of work experience has a negative effect on occupational status but exerts a positive effect on annual income of immigrants although it is quite surprising that immigrants with more work experience have lower occupational status the effect is relatively inconsequential that is the difference between having minimum and maximum years of work experience is approximately 39 occupation status points because we also control for years since immigration in this model the effect of work experience on occupational status measures the effect of origincountry work experience thus in terms of occupational attainment immigrants are better off when they arrive to the hostcountry after they finish schooling rather than to have worked in origin in their study of immigrants in the united states chiswick and miller also found that work experience acquired in the country of origin negatively impacted occupational status but positively affected immigrants earnings contrary to our hypothesis we do not find any evidence for a positive interaction between coethnic regional concentration and origincountry schooling that is the positive effect of education abroad on occupational status and annual income does not differ substantially between regions with high coethnic concentration and regions with low coethnic concentration we also hypothesized that a higher coethnic concentration in the region of residence would yield lower economic returns to german human capital with regards to this hypothesis our results are mixed in line with the hypothesis our results show that the positive effect of german education on occupational status and annual income indeed decreases with an increasing percentage of coethnics however the magnitude of the interaction effect is relatively small for example a oneunit standarddeviation increase in coethnic concentration decreases the positive effect of german education by only 029 status points regarding income the difference in the impact of german education is even smaller an increase of one standard deviation point in coethnic concentration decreases the positive effect of german education from 11 to 08 percent contrary to our hypothesis however our results also show that the positive effect of german language skills is slightly greater in regions with many coethnics as compared to the regions with fewer coethnics perhaps the immigrants proficient in german are more likely to serve as translators in the labor market whenever there are more coethnics because speaking german and having german education tended to be positively correlated we performed the analysis in model 3 again this time separating the two interaction terms the results available upon request show that although the negative effect on occupation and income of the interaction between coethnic concentration and german education does not change the positive interaction between coethnic concentration and german language skills is no longer significant 11 additional insights are gained through an examination of the control variables our results show a positive effect of weekly working hours on both occupational status and annual income doctor visits an indicator of health status are associated with lower occupational status but they have no significant effect on annual income occupational status and annual income increase the longer an immigrant has lived in germany finally our results show that even after accounting for the differences in immigrants social contacts duration in germany and originand destinationcountry human capital turkish immigrants have significantly lower occupational status but not income than do greek and eastern european immigrants 12 we found no significant cohort differences in occupational status and annual income of immigrants from including three dichotomous variables for immigrant cohorts table 4 about here table 4 presents the results for three sheaf coefficients ie general social contacts bridging social contacts and hostcountry human capital on the occupational status and annual income the results confirm the conclusions from the previous analyses using multiple indicators of social contacts and hostcountry human capital specifically table 4 clearly shows that general social contacts increase the annual income but have insignificant effect on the occupational status of immigrants bridging contacts with germans are much more important for immigrants occupational status than general social contacts but both types of social contacts seem to be equally important for the annual income thus when all indicators of bridging contacts are combined immigrants benefit from contact with germans also regarding annual income finally the results clearly show that the effect of hostcountry human capital on immigrants annual income and occupational status is about two and three times stronger respectively than the effect of both general social contacts and bridging contacts taken together conclusions and discussion using data on adult male immigrants from the german socioeconomic panel we examined the impact of social contacts on the occupational status and annual income of immigrants previous studies on the economic integration of immigrant workers have predominantly or even exclusively focused on contacts with coethnics little attention has been given to contacts with natives furthermore previous studies relied on crosssectional data making it impossible to test for the causal direction of social contacts the strength of our research design lies in the use of panel data on immigrant social contacts in particular contacts with natives which enables us to examine the causal effect of social contacts specifically we examine whether a positive correlation between social contacts and immigrants economic outcomes could be explained by reverse causality and spuriousness due to the accumulation of hostcountry human capital in addition we provide further insights into a relationship between social contacts and the economic outcomes of immigrants by studying the interactions between coethnic regional concentration and human capital our results confirm the hypothesis that the more social contacts immigrants have the better their economic outcomes there is evidence that immigrants who had a german partner and who volunteered during the previous year have marginally higher occupational status than do those who were single and who did not participate in volunteering similarly we find that having a partner and frequent contacts with family friends and neighbors lead to an increase in subsequent income the positive effects of general social contacts on immigrant occupational status and in particular annual income remain significant even when we take into account the possibility of reverse causality and measure immigrant social contacts up to five years prior to the assessment of occupational status and income there is also evidence for the hypothesis that bridging social contacts increase the occupational status and annual income of immigrants having a german partner as opposed to an ethnic partner and frequent contacts with germans lead to an increase in the occupational status and this relationship remains valid even after we measure the variables up to five years before the occupational status and take into account earlier investments in hostcountry human capital the model with sheaf coefficients suggests that having contacts with germans has a positive impact on immigrants annual income as well this means that the economic benefits from bridging social capital in particular when concerning the occupational status cannot be attributed to a reverse causality or postmigration human capital accumulation rather immigrants may indeed benefit from contact with natives because of the information and influence they provide thus it appears that there are different effects of social contacts on different economic outcomes immigrants benefit from having a partner and contacts with family friends and neighbors which help them find wellpaid jobs however to the extent these wellpaid jobs where immigrants find employment are dangerous dirty and degrading jobs which natives are reluctant to perform and higher status jobs would be more desirable immigrants are better off when having contacts with natives this finding is in line with other studies suggesting the importance of coethnic contacts in securing immigrants employment and sometimes income but their limited ability to access highstatus jobs our results also show that at least in germany coethnic regional concentration has no significant effect on immigrants occupational status and annual income it is possible that germany simply lacks substantial ethnic concentrations like the cubans in miami or the chinese in san francisco that significantly influence immigrants economic outcomes for example it could be that the occupational status and income of immigrants are only affected by ethnic concentration if it exceeds certain thresholds values this could also explain why we do not find evidence for the hypothesized positive interaction on labor market outcomes we expected to see between coethnic concentration in the region of residence and origincountry schooling moreover this might also explain only partial confirmation of the hypothesized negative interaction effects between coethnic concentration and hostcountry human capital footnotes 1 people who were employed for a very short time were excluded from the analyses these include people who reported an annual income lower than 6000 euros and those who worked fewer than 16 hours per week 2 it should be mentioned that as with all panel data the gsoep survey is subject to sample attrition the response rate in the first wave in 1984 exceeded 70 percent in both samples b and d in 2004 the response rate was about 25 percent in sample b and about 45 percent in sample d the main causes of attrition were unsuccessful interviews and ineffective tracking of individuals throughout the survey attrition was also related to mortality and migratory movements special measures were taken to reduce attrition in the subsequent waves temporary dropouts or persons who could not be successfully interviewed in a given year were followed until there were two consecutive temporary dropouts of all household members or a final refusal 2 and3 the results show that it would not change our conclusions for occupational status and annual income if social contacts are lagged up to five years except for the relationship between volunteering and annual income which becomes positive and significant 8 although our theoretical arguments about the spurious effect of social capital are mainly concerned with social contacts with natives we included all indicators of social contacts in the models this is because of the lack of information about the composition of the variables for frequency of social contacts and volunteering which may involve both coethnic and german contacts 9 we also tested whether the effect of ethnic concentration in the region of residence on the occupational status and annual income was nonlinear by including three dichotomous variables for ethnic concentration nevertheless this is not the case 10 contrary to what one would expect the economic returns to origincountry schooling are slightly larger or the same than the returns to hostcountry schooling a possible explanation for this finding is that a very small proportion of immigrants invested in additional education in germany which might have had a substantial economic payoff 11 we also tested whether the effect of coethnic concentration in the region of residence varied by immigrants length of stay in germany but this is not the case 12 we also checked whether there are interethnic differences in the effect of social contacts on immigrants occupational status and income the results indicate that all immigrant groups benefit economically from having social contacts although different types and sources of social contacts are important among immigrant groups for all but third country immigrants having a german or a coethnic partner has a positive effect on the occupational status or income similarly having general social contacts is beneficial for all but eastern european and exyugoslavian immigrants however the presumed positive effect from having contacts with germans is less clear specifically only italians and exyugoslavians benefit economically from having german friends finally living in regions with high concentrations of coethnics does not affect the economic outcomes of all but east european and spanish immigrants for whom coethnic concentration has a detrimental effect on the economic outcomes alternatively the insignificant effect of coethnic concentration could be explained by the opposing effects of selection of immigrants in the regions with high coethnic concentration and coethnic concentration on labor market outcomes for example in their study on latino immigrants in the united states chavez et al showed that ethnic concentration initially facilitates immigrants wages by enabling them to communicate in their native language and providing assistance in the hostcountry labor market in the long run however coethnic concentration seemed to reduce immigrants opportunities for gainful employment given a small number of recent immigrants in our sample it is difficult to substantiate any speculations concerning the insignificant effects of coethnic concentration in the region of residence and small interaction effects between ethnic concentration and originand hostcountry human capital this could be examined more effectively through data on more recent immigrants who are still in the process of acquiring bridging social capital and hostcountry human capital most of the previous research highlights the shortterm benefits of coethnic family and friends in immigrant economic integration in this study we also show that even immigrants who have already lived in the hostcountry for an extended period of time benefit from social contacts future research could analyze whether and how the effects of social contact change over time previous literature suggests that coethnic social contacts are most critical for immigrants upon arrival to the hostcountry when they lack hostcountry language skills and credentials however the importance of social contacts may also increase with the time spent in the hostcountry when immigrants acquire better and more resourceful contact with coethnics and natives migration studies could also benefit from more detailed measures of bonding and bridging social contacts this would enable the examination of the exact mechanisms for the positive effect of social contacts for example although we assume that immigrants benefit from bridging contacts with germans because of superior information and recommendations to prospective employers provided by such contacts immigrants with greater contacts with germans may also have more diverse networks by incorporating a broader and more dynamic view of social contact into future research we can better understand the impact of bonding and bridging social contacts on the economic integration of immigrants the model also includes a set of dummy variables for survey year the continuous variables of education abroad education in germany german language skills and ethnic concentration are meancentered the three sheaf coefficients are general social contacts comprising of frequency of contacts and volunteering activity bridging contacts comprising of three indicators of german contacts and german partner versus singleethnic partner and hostcountry human capital comprising of german education and german language skills the model also includes ethnic concentration education abroad work experience work experience squared years since migration weekly working hours doctor visits immigrant group and a set of dummy variables for survey year

a panel study of immigrants in germany using data from the german socioeconomic panel we examined the impact of social contacts on immigrant occupational status and income in addition to general social contacts we also analyzed the effects of bonding ie coethnic and bridging ie interethnic ties on economic outcomes results show that general social contacts have a positive effect on the occupational status and in particular annual income of immigrants we also find that bridging ties with germans lead to higher occupational status but not to increased income these effects remain visible even when social contacts are measured at least one year prior to the economic outcomes as well as when earlier investments in german human capital are considered finally we show that coethnic concentration in the region of residence weakly affects economic returns to german language proficiency and schooling

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introduction indigenous food sovereignty has been a living reality for indigenous peoples across turtle island who have sustained highly localized food systems since time immemorial 12 ifs recognizes the sacred participatory relationships between indigenous peoples and their foods concretizing practices and knowledges that are shared to support indigenous food systems 1 indigenous food systems are rich in ecological placebased knowledge reflecting significant relationships to the landscape and have evolved distinctly within communities over generations 2 3 4 ifs is an actionoriented approach that supports these placebased food systems through activities that consider the sociocultural meanings acquisition and processing techniques of indigenous foods such as hunting fishing trapping and foraging 3 5 6 7 these activities are embedded within processes that support indigenous knowledges connections to land wellbeing and selfdetermination 9 10 11 indigenous food sovereignty has gained momentum in the last decade as indigenous communities work towards revitalizing indigenous foodways 110 however the uptake of these initiatives and associated research has predominantly occurred among northern and remote indigenous communities within canada in these contexts culturebased camps or ontheland programs are common pathways to strengthen ifs 10 12 13 14 gardening projects with associated food literacy programs or preservation workshops are more common in southern indigenous communities to strengthen landbased connections and revitalize indigenous knowledges and skills 4815 this existing body of research offers important insights into how communities are implementing initiatives that can promote ifs but findings are contextual to these spaces and places with limited examples documenting communitybased ifs initiatives within urban environments there are a myriad of initiatives working towards ifs reflective of the knowledge food skills and relationship to land held within each community the published literature that explores ways to promote ifs within urban environments primarily consists of food skill workshops and establishing indigenous gardens 111617 these initiatives are significant for urban indigenous people to share knowledges employ selfdetermination and reclaim identity by practicing these skills and their cultures in the city 111617 yet there has been little research todate that has examined the geographies and social contexts of urban environments 1819 this study aimed to address these gaps to better understand how urban environments influence ifs initiatives urban indigenous food environments the prevalence of food insecurity among indigenous peoples within canada is a direct result of colonial policies and structures that have had detrimental impacts on indigenous food systems 1 20 21 22 intergenerational impacts of colonial policies have disconnected indigenous peoples living in urban centres from the land shaping health disparities in distinct ways 18 indigenous peoples living in cities face distinct impacts to accessing and engaging in indigenous food systems when compared to their rural remote and onreserve counterparts 2324 research suggests that urban indigenous peoples are frequently unable to fully participate in indigenous food systems and local food sharing practices because they are dispossessed from their physical and social environments 182526 as such they may have divergent relationships to the land and skills necessary to acquire and process or prepare indigenous foods 11 urbanization is also a challenge to accessibility of indigenous foods as marketbased foods are more readily available in the local environment 26 the majority relies on the industrial food chain in urban centres even though food can be accessed through alternative food networks which include local farmers hunters and gatherers 27 these overlapping systems make up the pathways representing how indigenous food sources are accessed within the city often relying on social and cultural connections to home and other indigenous networks 18 25 26 27 indigenous peoples within canada are becoming increasingly urbanized migrating to urban centres more than any other segment of the population 28 within the province of ontario 855 per cent of first nations métis and inuit live outside of their home communities 2829 while 60 per cent of first and second generation urban indigenous people retain connections there are many who have been living in cities for two or three generations and are disconnected from their indigenous foods and practices 2330 at the same time urban indigenous families would prefer to consume indigenous foods more often due to their connections to wellness land and culture however demand for these nutrient dense foods is often unmet in southern and urban settings 1118 despite the growing numbers of indigenous peoples living within these diverse urban environments there are few studies that consider the experiences of indigenous peoples in southern regions and cities where less visible circumstances of food insecurity are occurring 2324 a case study of the indigenous food and medicine garden at western university highlights how growing traditional foods and medicines on campus supports indigenous selfdetermination and land reclamation but recognizes the institutional constraints that limit the potential of this ifs initiative 17 the covid19 pandemic has simultaneously heightened these challenges in a range of environments 31 particularly in cities where an emerging number of indigenousled grassroots efforts are occurring 3233 and becoming places of indigenous resurgence 34 this study highlights the indigenousled communitybased food sovereignty initiatives taking place in four urban centres within southern ontario canada the research presented in this paper is part of a larger study 35 that examined how the urban environment impacts local ifs initiatives this paper focuses on findings specific to the social dimension of urban food environments highlighting principles and practices that are components of ifs initiatives materials and methods community context the study took place within waterloo and wellington regions in southern ontario these neighbouring regions include four major urban centres kitchenerwaterloo guelph and cambridge all connected by the grand river or its tributaries 36 these cities have a total population of 761391 according to 2020 census data 37 it is estimated the region is home to 19285 selfdeclared indigenous peoples including first nations métis and inuit together representing 15 of the total population 3839 the region has seen an increase in urban ifs initiatives within recent years in response to interest within the indigenous community to reconnect with cultural foodways and support food security indigenousled initiatives have emerged in connections to postsecondary institutions indigenous organizations and grassroots community efforts this study is embedded within a broader canadian institutes for health research funded research project which aims to bridge spaces and places between onreserve urban and educational environments to strengthen pathways towards indigenous food sovereignty across southern ontario four existing ifs initiatives within this region were identified during the data collection period that began in the summer of 2020 relationships were first established with wisahkotewinowak an indigenous garden collective that maintained four garden sites across the region 40 at the time the collective provided landbased learning opportunities for high school and postsecondary students the foods and medicines harvested from the gardens were shared with postsecondary indigenous student centres locally through food preserving workshops and a food share program in partnership with a local indigenous agency the waterloo region indigenous food sovereignty collective was also included as it had developed a neighbourhood approach which began in response to the food insecurity needs at the onset of the pandemic 41 the waterloo region collective had 18 gardens that ranged from an acre to individual backyard gardens shatitsirótha the university of waterloo indigenous student centre was also involved and maintained a small produce garden medicine gardens and a ceremonial fire site 42 along with the north end harvest market in guelph which provides access to free produce and culturally significant foods to the local indigenous community theoretical frameworks and study design indigenous research methodologies guided the study process by approaching the research through continual reflexivity of relationships actions and experiences to prioritize indigenous ways of knowing 43 44 45 these processes were applied by building relationships with indigenous community members to centre participant voices and maintain responsibilities to those relationships 4647 communitybased participatory research methodology was applied to the study design as it is fundamentally driven by relationships and decolonizing power differences 48 cbpr is a recommended approach when working with indigenous communities 464749 the participatory elements of cbpr supported the relational actionoriented nature of ifs 1 the participatory nature of ifs provided opportunities for the first author to build relationships and develop a research inquiry that could be useful accessible and give voice to the community members leading ifs initiatives in these urban contexts participating in ifs initiatives was also an important aspect of reducing power differentials between the lead researcher and the community particularly the lead author of this study is a nonindigenous researcher who moved to the region at the start of her msc program she relied on the second and third author to support her gaining trust and reliability within the community as they both live and work with indigenous communities in the region by relying on these preexisting relationships the lead author was able to develop independent relationships with community members and connect with other ifs initiatives in the area by working alongside and learning with indigenous peoples and their initiatives she was able to combine the knowledge gained through the research and relationship building on the land into useful results and recommendations cbpr allows for research with indigenous communities to be validated by following the ocap ® principles of ownership control access and possession of knowledge 4950 the usai research framework also guided the research process and design 51 the study applied the principles of utility selfvoicing access and interrelationality through each phase of the research a research advisory committee was established to bring together community partners to advise research activities relating to the urban component of the cihr grant this group included representatives from indigenous student centres on postsecondary campuses leadership from local indigenous organizations community members engaged in ifs initiatives as well as other research faculty and students a few members of the committee were recruited as research participants and other research participants were invited to join the meetings as the formal research process unfolded research updates and findings were continuously shared with community members and research participants at research advisory meetings to ensure knowledge presented was accurate and authentic research participants and community members had an active voice in contributing to the development of the research these relational processes were integral for this research to be valid useful and relevant to those individuals and networks leading the local communitybased ifs initiatives participant recruitment purposive sampling was utilized to recruit participants through relationships established with the wisahkotewinowak collective to then include other organizations and initiatives the communitybased aspect of this research helped identify participants who were engaged in local ifs initiatives selfidentified as indigenous and lived in the urban centres of kitchenerwaterloo guelph or cambridge ontario snowball sampling was then used to build the sample through local networks 52 drawing on the relationships participants held with others in the community once invited formally via email participants were offered asemma to affirm the intentionality of the research purpose 53 and respect cultural protocols acknowledged by the local indigenous community recruitment and data collection occurred between august and november 2020 ethical approval was received from the university of guelph research ethics board seven participants were recruited to participate in the study at the time of recruitment five participants were living in kitchenerwaterloo one in cambridge and one in guelph two participants identified as male four identified as female and one identified as twospirit two of the participants were youth four were adults and one participant was elder participants were given the option to be identified by their name or a pseudonym participant characteristics are included in table 1 data collection and analysis a semistructured interview guide was developed in collaboration with the research advisory committee to explore participants perspectives of indigenous foods engagement in urban ifs initiatives impacts of the urban setting as well as gather their recommendations to strengthen this work in the future the interviews lasted between one hour and two hours in length interviews were held either inperson or virtually through a secure video conferencing platform inperson interviews were conducted outdoors at a safe physical distance to satisfy covid19 protocols at the time interviews were recorded with the consent of the interviewee one participant chose not to be recorded instead they typed out their responses to the list of interview questions after conversations were shared discussing the study concepts this document was treated as the transcript for data analysis audiorecorded interviews were transcribed verbatim by the lead author with support from an undergraduate student individual transcripts and quotations incorporated into the results were shared with participants as a form of member checking 53 allowing participants to edit quotations so their words were accurately reflected and any unwanted identifiable details could be removed at the request of participants additional slight edits were made to their quotes to improve readability the lead author completed a thematic analysis of the transcripts where emerging themes and concepts were highlighted for further exploration codes were then highlighted and organized using nvivo 12 software a combination of deductive and inductive coding was applied to identify themes in the data coding was complete once codes captured the patterns and outliers within the data 52 preliminary themes were shared with the research advisory committee and interested participants for feedback before results were finalized these processes associated with the previously identified methodologies strengthened the overall research by prioritizing indigenous knowledge and centring participant voices 4854 results thematic analysis revealed four interrelated themes landbased knowledge and relationships land and foodbased practices relational principles and place participants engaged in five land and foodbased practices seed saving growing and gathering food hunting and fishing processing and preserving food and sharing and distributing food these practices centred around landbased knowledge and relationships guided by principles of responsibility relationality and reciprocity the relatedness of these themes are presented in a conceptual model this model illustrates components of urban ifs initiatives which are influenced by place place is situated in the outer layer of the model which contextualizes the social and physical aspects of the urban environments that make up the grand river territory the findings presented in this paper highlight how the three principles were evident in land and foodbased practices suggesting these principles and practices construct the processes that are integral to urban ifs initiatives components of urban ifs initiatives which are influenced by place place is situated in the outer layer of the model which contextualizes the social and physical aspects of the urban environments that make up the grand river territory the findings presented in this paper highlight how the three principles were evident in land and foodbased practices suggesting these principles and practices construct the processes that are integral to urban ifs initiatives relationality responsibility and reciprocity when describing engagement in urban ifs initiatives all participants spoke about relationships to land seeds plants food and people in the community demonstrating that relationships were integral throughout ifs initiatives participants enacted these relationships by being relational responsible and reciprocal in the ways they carried out landand foodbased practices these themes were categorized as relational principles that surround landand foodbased practices as illustrated in the model simultaneously supporting and interacting with each other relationality encourages responsibility which requires reciprocity all participants spoke about being relational when carrying out land and foodbased practices these conversations stemmed from the way participants described their personal relationships with food interviews contained discussions around definitions or interpretations of indigenous or traditional foods it became apparent that what connected participants to these foods was their relationships sarina spoke to the emotional significance of indigenous foods comparing the feeling to the love you have for a sibling she stated i feel like that emotion is mirrored in a relationship with food because it is such a large part of how you are supportedbecause you wouldnt be able to live without the foods beth spoke about how there is a spiritual significance to food grown and shared in community she explained theres a ceremony to it right theres a thankfulness theres restraint versus referring to market foods justits on sale ill take the whole shelf these illustrations demonstrate there is a sacred and emotional relationship to indigenous foods relationality responsibility and reciprocity when describing engagement in urban ifs initiatives all participants spoke about relationships to land seeds plants food and people in the community demonstrating that relationships were integral throughout ifs initiatives participants enacted these relationships by being relational responsible and reciprocal in the ways they carried out landand foodbased practices these themes were categorized as relational principles that surround landand foodbased practices as illustrated in the model simultaneously supporting and interacting with each other relationality encourages responsibility which requires reciprocity all participants spoke about being relational when carrying out land and foodbased practices these conversations stemmed from the way participants described their personal relationships with food interviews contained discussions around definitions or interpretations of indigenous or traditional foods it became apparent that what connected participants to these foods was their relationships sarina spoke to the emotional significance of indigenous foods comparing the feeling to the love you have for a sibling she stated i feel like that emotion is mirrored in a relationship with food because it is such a large part of how you are supportedbecause you wouldnt be able to live without the foods beth spoke about how there is a spiritual significance to food grown and shared in community she explained theres a ceremony to it right theres a thankfulness theres restraint versus referring to market foods justits on sale ill take the whole shelf these illustrations demonstrate there is a sacred and emotional relationship to indigenous foods this relational understanding of food extends to how people work together in community to support ifs initiatives rachel recognized how ifs initiatives require participation for many people to come together and do the work strengthening social networks she commented now that theres more community involved theres some people that have made new friends or made new connections and have more people to reach out to therefore being relational within these contexts appears to be a core principle of urban ifs initiatives and builds community five participants spoke about how being relational comes by knowing ones responsibilities participants reflected on their own teachings about their role as a human being in creation and having a responsibility to the land for example nookomis talked about knowing how to be responsible pointing out that acting or living responsibly begins with the anishinaabe creation story creation ensured that all created holds a part of creationspirit it might be said that this holding of spirit was the first commitmentresponsibilitytreaty between creator and that created this responsibility honours the reciprocity how we give back to creations garden mother earth responsibility to land is made possible in urban centres by participating in ifs initiatives which foster relationshipmaking with all creation for instance beth explained how she understands her responsibility for the land around her she summed up well because im on it and my feet are on it so where creator has my feet there i will be responsible therefore being responsible for the land does not matter where you are physically located rather its about how you relate to the land you are on reciprocity also emerged as a value participants carried throughout their engagement in ifs initiatives reciprocity was required to uphold responsibilities and support relationships two participants spoke directly about how reciprocity was enacted through local food sharing in response to gifts provided from land and creation sarina reflected the reciprocal aspects of food sharing activities its understanding i have much more than i need and i have the capacity to share with others so i need to do that in order to satisfy my responsibility to the land and others around me i see it as connecting to our sense of responsibility that is linked to reciprocity inherently we have a responsibility to the land and that is to first and foremost harvest in a respectful way but then i think that responsibility extends to the way we share the food in this quote sarina speaks to how reciprocity fulfills responsibility and strengthens relationshipnot just to people when food is shared with but also with the land nookomis extended this idea noting that reciprocity is inherently linked to honouring responsibility to creation with humility and gratitude as creator knows me i act on my original instructions i walk this red path in the physical realm to observe listen and learn from seeds plants and all those other relations our kin we are all interconnected one of the ways i honour with humility and gratitude this earth our mother and all ancestors is by being a seed keeper of a number of plantsrootsbarksflowersseeds specific to my clan i do this in ceremony with community to produce gather prepare feast and for healing i do this for now and for the generations of all our relations whose faces we have yet to see reciprocity places a sense of accountability on the responsibilities and relationships to land and community creation provides gifts that can be reciprocated back to the land by sharing food knowledge and ceremony with others in community who also belong to the land reciprocity is an important value displayed within urban ifs initiatives as it ensures a continual cycle of giving and receiving that is generated from a place of humility and generosity this cycle of reciprocity relationality and responsibility guided land and foodbased practices landand foodbased practices participants in this study spoke about five landand foodbased practices that were core components of local ifs initiatives six participants discussed the significance of seeds and seed saving as a practice rachel explained that part of her groups efforts was designated solely for seed saving which was growing enough seed to share with community next year beth explained how planting and saving seeds are essential to initiate and continue indigenous food sovereignty efforts it starts with seeds right every person having seeds in their hand and those seeds growing food for themselves their families their community but also being able to put some aside for seeds again theres that cycle of provision giving and preparation provision for your family for your neighbour giving of seeds back to community for others who dont have what they need yet participants shared how seed saving was about honouring relationships and responsibilities for instance garrison shared the importance of growing and saving succotash beans and lenape squash to connect with his identity from his ancestral territory beth recognized the significance of growing white corn from six nations in the urban garden spaces which are situated on haudenosaunee territory she grew this corn out of respect for haudenosaunee people explaining because of the granting of the land in this territory to them which we all know has not been fulfilled but just doing my best to honour their traditions and their seeds on the land she continued and explained that despite not being haudenosaunee herself making sure these seeds are in the ground is a way to show mutual respect for her indigenous sisters in community growing food was the most common practice to acquire indigenous foods and medicines in the city as all the local initiatives discussed by the participants involved gardens four participants also spoke about gathering food by foraging and two more about gathering sap from maple trees within the city limits participants also described how their gardens were used to grow for different purposes including for seed medicines indigenous foods or conventional garden produce several participants recognized the importance of cultivating culturally significant foods in urban spaces to strengthen relationships to the land they were growing on and honour the responsibility to indigenous ancestors who cultivated these plant varieties over thousands of years a list of these indigenous plants described specifically by garrison dave and lori are listed in table 2 garrison described how growing plants and saving seeds supported the relationship he held to land while also upholding responsibilities planting and saving seeds and planting again are these beautiful ways of really being able to witness the unfolding aspect of life so i was always really intrigued by that and really excited to be able to use my hands to cocreate with in relationship with these plants but also in relationship with the creator and what the creator had intended for us to be right cause these relationship beings when we receive from those plants that we are also that our responsibility is to save those seeds and keep that plant alive six participants spoke about hunting or fishing when describing access to culturally significant foods around ifs initiatives three were involved in hunting and fishing practices locally but only dave spoke about fishing within an urban area for personal consumption none of the participants mentioned hunting or fishing as activities that took place within their ifs initiatives suggesting limited access to these foods within urban settings rachel described how she would like to increase opportunities for hunting and fishing within the region noting we dont have very many hunters right now but we are hoping to teach some more so we are basically mentoring those who dont know three others had personal connections to family or community that supported access to wild meat and fish beth mentioned my dad is not first nations but he was a hunter and so we would eat game like he would fish and hunt so we would have wild food from that this suggests the importance of relationships as well as connections to knowledge and practice that are necessary to access game locally while living within urban environments this aspect of relationality was similarly emphasized by lori who noted the difference between her social networks to access wild meat after relocating to ontario back in saskatchewan when i was in an urban setting i had a little bit more access to wild meat because i had a network of people and so it was still relatively easy to get or to trade for wild meat but when i got out here i didnt have that network and i still dont really have strong enough ties here to access wild meat another practice participants described was processing and preserving foods five participants mentioned how they processed or preserved locally grown produce to create more variety in food availability and extend the growing season dave and lori had connections to indigenous student centres on campus so foods harvested from the gardens supported foodbased programming for indigenous students for lori this included soup and bannock days and the fall feast staff and students would prepare the food for these events beth and rachel talked about how they relied on people in the community with canning skills to support food processing and preserving efforts rachel described how the community helped forage and harvest fruits and vegetables from their backyards and city spaces to then be processed and preserved she explained weve also been collecting equipment so we have five pressure canners for the canners that are community canners this sharing of equipment and responsibilities demonstrates how individuals in the community can support ifs initiatives by participating in activities where they can best lend their resources skills labour and time all participants spoke about sharing food sharing happened through organizational distribution avenues as well as more informally through personal networks dave and rachel talked about how food distribution pathways were created within their ifs work in response to the covid19 pandemic to increase access points and feed the local urban indigenous community dave spoke about an indigenous food basket sharing program that began with a partnering indigenous organization recalling we did our first official give away of food and did thirteen boxes of produce to indigenous community members similarly rachel expressed in the beginning we had about 30 people we were feeding regularly with either a weekly grocery bin of different foods to make themselves or meals made every day an unexpected result that rachel shared was that she would receive kind messages from members of the urban indigenous community who were not only in need of food but social connection lori also reflected on how food was a way to support relationships in the community by making and sharing food to help people stay connected sarina spoke to these broader impacts i think that our work has not only been able to nourish bodies in terms of nutrients but also souls and spirits of people not everybody that weve been giving boxes to are in dire dire need of food physically but they may be kind of spiritually deprived because they are stuck at home doing zoom calls by themselves rachel described how sharing was inherent throughout land and foodbased practices stating we have seed sharing thats been happening food growing meal making and food sharing the practice of sharing was an important way to build relationships and uphold responsibilities to community in reciprocal ways for instance beth stated its looking at what i have what im responsible for as my communitys not mine and sharing my time my resources that im responsible for with my neighbours my brothers and sisters in community sharing strengthened relationships in response to fulfilling responsibilities sarina described these interactions demonstrating how relationships are central to ifs initiatives we kind of operate in a circular way like were all equal and thats translated to how we share our food and i think that theres something refreshing but also beautiful about it because in each exchange between people throughout the process of food growing and food giving theres a reciprocal thing going on that builds relationship because the entire process has to do with community really and relationship with others not only do we rely on volunteers and the combined collective work of all of us but we also rely on the earth and the land to teach us and help us through the process sharing food was not simply a practice but a significant process that unified applications of responsibility relationality and reciprocity within ifs initiatives strengthening relationships between land the natural environment and the social networks within community the model conceptualizes urban ifs initiatives across grand river territory but it also represents this web of relationships between all elements within the environment this idea is noted by nookomis who shared creation is the system it is holistic and sustainable it is our identity there are no separations between two leggeds and all else created we are of the land this continual thread weaves through each landand foodbased practice connecting these actions as components of a more holistic system clearly governed by a set of principles that are really at the heart of ifs initiatives being relational responsible and reciprocal discussion overall the results of this exploratory study offer an understanding of communitybased ifs initiatives within urban environments the participants in this study demonstrated that relationality responsibility and reciprocity are core values of urban ifs initiatives which guided landand foodbased practices the model demonstrates how ifs initiatives are interdependent a connection to land is essential for food to be grown and growing food to share with community fulfills a responsibility to the land participating in land and foodbased practices connects people to their responsibilities by saving seeds growing processing and sharing food in relational and reciprocal ways this model conceptualizes an urban indigenous food system within grand river territory identifying key processes that work towards ifs this discussion section engages with principles of ifs and describes how relationality responsibility and reciprocity are demonstrated within communitybased ifs initiatives these processes can be applied to other urban indigenous communities offering a pathway towards strengthening ifs the results from this study concur with other research on ifs and bring new understandings of ifs within the urban context participants in this study identified that indigenous foods have a sacred aspect to them because of the relationship one has with their food this parallels with findings from another urbanbased study in winnipeg manitoba where urban indigenous peoples recognized the relationship with food as a spiritual process the growing harvesting preparing eating and sharing cultural food was an act of ceremony 11 the spiritual significance of indigenous foods has been well documented in the literature 4811265556 but this study adds how urban indigenous peoples are enacting the ifs principle of food as sacred through urban initiatives the sacred emotional and relational significance of indigenous foods was recognized by participants in their understanding of responsibilities stemming from the innate relationship with land or creator this was also acknowledged by robin 9 who states relationships to the land are also important in helping to fulfil the roles and responsibilities we have made towards the land as caretakers responsibilities were fulfilled by active participation in land and foodbased practices through the planting harvesting processing and sharing food with others in community as has been identified by michnikthompsonand beardy 13 their study examined a northern food initiative at garden hill first nation and described the sacredness of food requires active participation in landbased activities similarly in the southern community of kahnawàke delormier and colleagues 4 have highlighted how haudenosaunee food sovereignty focuses on restoring indigenous cultural responsibilities and relationships to land each other and the natural world this research aligns with the findings from our study as participants honoured the sacredness of food by displaying responsibility and participating in ifs initiatives participants in this study upheld responsibilities to land and community primarily through the sharing of food as an act of reciprocity recognizing the gift of food that comes from the land cidro and colleagues 11 also describe the connection that cultural foods provided to the land through reciprocity within the city of winnipeg manitoba participants described that they could still be connected to the land through their relations who gifted and shared food despite not always having access to land or being able to engage in foodbased activities this demonstrates that reciprocal relationships extend beyond the people who harvested food and highlights the larger process of food giving up its life to support people 11 these findings are consistent with results presented in this paper confirming that relationships are the mitigating factor that links people to land and place in urban settingsand reciprocity ensures the sacredness of these relationships continues the sacred gift of food connects urban indigenous peoples to land and community unifying the spiritual relations in the local environment the relational principles that guide landand foodbased practices support processes of selfdetermination in this study the urban indigenous community collectively demonstrated acts of selfdetermination by saving seeds and deciding what foods and plant medicines to grow participants chose to cultivate foods they held personal connections to and also grew varieties that held local significance for the anishinaabe and haudenosaunee peoples recognizing the treaty territory that they currently live in these selfgoverning practices are what daigle 5 acknowledges as central to this larger process of decolonization and selfdetermination the decisionmaking processes and social systems are pathways to selfdetermination that can ensure sustainable food systems 4 participants in this study similarly demonstrated selfdetermination through establishing processes to harvest preserve and distribute food within the community these food sharing practices valued food as a giftnot a commodity to be exchanged transactionally sharing food was a significant landand foodbased practice but also a process that enabled participants to be relational responsible and reciprocal in communitybased ifs initiatives in this study sharing food supported social relations and access to culturally significant foods to the wider indigenous community previous research shows how sharing and trading promotes community and social cohesion while also increasing access to culturally significant foods for indigenous peoples in the city 1118232426 the indigenous community in the city of saskatoon recognized that preparing and eating food within kinship networks contributes to resistance to the dominant insecure food system 27 therefore implementing food sharing practices offers an alternative approach for urban indigenous peoples to determine their food systems sharing food is embedded within anishinaabe and haudenosaunee food systems and practices so enacting these processes in the urban centres supports selfdetermination and strengthens community relations growing food supports ifs through very tangible ways of increasing food availability but implementing processes and systems that govern how food is distributed and shared within community promote selfdetermination foster reciprocity and collective citizenship 57 gardening initiatives can increase community control over food produced which can support a sharing economy that meets community needs 13 enacting ifs initiatives within urban environments prioritizes responsibilities over rights as exhibited in this study by participants taking care of each other and the land timler and sandy 58 offer that shifting our understanding of food and land from one of resource to one of relationship creates the opportunity to rebuild relationships through reciprocity among neighbours in responsible ways perhaps implementing ifs initiatives that centre relationality responsibility and reciprocity provides a pathway towards selfdetermined food systems within urban environments ifs initiatives strengthen indigenous foodways that support local food insecurity needs 25 while building community cohesion and wellness 58 selfdetermination over indigenous foods and food systems contributes to community wellbeing through sharing food practices ceremony and social gatherings 5960 recent findings from a syilxled ifs initiative that revitalized sockeye salmon in the okanagan river basin of british columbia resulted in enhanced cultural connectedness increased a sense of belonging and wellbeing 61 indigenous food systems embody healthy processes and acquisition to nutritionally and culturally significant foods 62656 previous research has established the importance of community to foster relationships with land and carry out foodbased practices which are inherently collective activities 11186263 as pawlowskamainville 63 state food sovereignty needs a community to feed a community participants in the present study demonstrated how community was in essence created by engaging in ifs initiatives sharing not only of food but seeds knowledge and resources are key components of urban ifs initiatives that enabled participants to be relational responsible and reciprocal in selfdetermining ways therefore ifs initiatives can create supportive social environments in the urban context resulting in physiologically spiritually and emotionally healthy people and communities recommendations for future research this research highlights how ifs initiatives are taking shape in urban environments within southern ontario providing a novel understanding of how urban indigenous peoples are pursuing food sovereignty initiatives further research is however necessary to understand how the principles and practices of other urban indigenous communities compare to the findings presented in this study communities must define what approaches work best for them because of the diverse sociohistorical circumstances that affect local experiences of ifs 596264 indigenous food systems involve governance structures based on the ethics of reciprocity sharing and valuing food as a sacred gift 26365 therefore further research could explore how food economies based on sharing harvesting and gifting may provide alternative approaches that increase food security food access and support the decolonizing goals of ifs within urban environments at the local and community levels there are opportunities to bring indigenous peoples and settler food actors into dialogue for solidarity building 5 and equity within local and regional placebased food systems 66 bringing together key actors within the community can be completed through a collaborative crosssector governance model network or space that can work towards policies that support selfdetermination within indigenous food systems and practices the indigenous food circle based out of thunder bay 67 provides an example of the unique partnership described between the local food policy council health unit indigenous communities and postsecondary institution at the same time indigenous women must be centred in these spaces because indigenous leadership that follows a matriarchal system of governance is a move towards selfdetermination 968 there is a gendered element to indigenous food sovereignty work not examined in this study warranting direction for further research strengths and limitations this study is the first to document the growing movement of urban ifs initiatives taking place in grand river territory highlighting how urban indigenous peoples are engaging in landand foodbased practices in selfdetermined ways a strength of this study is the application of cbpr and relational accountability built within the wisahkotewinowak collective and the wider communitybased work taking place in the region through the participatory communitybased nature of this study results supported and strengthened the innovation around ifs pointing towards ways this work can expand to other urban ifs movements this research also highlights opportunities for nonindigenous people to participate in and learn from indigenous community members leading food sovereignty work to create sustainable and supportive environments in urban contexts the location and food availability are important to acknowledge as the local context of this study limits the generalizability of the research findings to other southern urban contexts growing food is a common ifs practice within southern ontario because of its ideal climate and arable land however other urban contexts may reflect different ifs practices depending on the local food availability and other environmental factors another limitation of this study was implementing communitybased research and data collection with human participants during the onset of a global pandemic covid19 limited inperson gatherings and opportunities to network and recruit participants through community events this resulted in a smaller sample size than anticipated this also challenged original data collection and dissemination plans delaying timelines and having to adjust methods that complied with ethics approval instead of holding inperson interviews video conferencing was prioritized and a knowledge sharing presentation was held virtually conclusions indigenous food initiatives continue growing at the grassroots level across turtle island despite this there is limited research that explores ifs initiatives in urbanized centres within canada the research provides novel insights to the body of the ifs literature by considering how the urban environment impacts ifs initiatives by examining components of ifs initiatives this study offers considerations for what constitutes indigenous food systems in the urban setting the core values of relationality responsibility and reciprocity demonstrate how social relationships can be structured to carry out landand foodbased practices to promote selfdetermination and increase community wellbeing these results also provide insight into ways that both indigenous and nonindigenous people living in a common place can come into relationships to cultivate care for the land and the community by participating in urban ifs initiatives growing harvesting and sharing food together can help foster a respectful way of living that honours treaty responsibilities and supports the sustainability of ifs initiatives into the future data availability statement the data are not publicly available due to privacy acknowledgments em was supported with internal funding provided by the university of guelph including the harshman graduate scholarship in food systems and the estill family graduate scholarship for research in the arboretum we are grateful to the participants whose voices are included in this study without your involvement this research would not have been possible author contributions conceptualization em htn and ka methodology em htn and ka investigation em resources htn writingoriginal draft preparation em writingreview and editing em htn and ka supervision htn and ka project administration em funding acquisition htn all authors have read and agreed to the published version of the manuscript funding this research was funded by the canadian institutes for health research cihrirsc 0536002672 institutional review board statement the study was conducted according to the guidelines of the declaration of helsinki and approved by the university of guelph reb in june 2020 informed consent statement informed consent was obtained from all participants involved in the study written informed consent has been obtained from the participants to publish this paper

there are collective movements of indigenous food sovereignty ifs initiatives taking up place and space within urban environments across the grand river territory within southern ontario canada indigenous peoples living within urban centres are often displaced from their home territories and are seeking opportunities to reconnect with culture and identity through land and food this research was guided by indigenous research methodologies and applied communitybased participatory research to highlight experiences from seven indigenous community members engaged in ifs programming and practice thematic analysis revealed four interrelated themes illustrated by a conceptual model landbased knowledge and relationships land and foodbased practices relational principles and place participants engaged in five land and foodbased practices seed saving growing and gathering food hunting and fishing processing and preserving food and sharing and distributing guided by three relational principles responsibility relationality and reciprocity framed by the social and physical environments of the place key findings revealed that employing selfdetermined processes to grow harvest and share food among the indigenous community provide pathways towards ifs this study is the first to explore urban ifs initiatives within this region offering a novel understanding of how these initiatives are taking shape within urban environments

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background community based participatory research highly values the engagement of the community in all aspects of the research process 12 building trust and being able to reach communities and groups most affected by the health issue of concern remains a major challenge for all those interested in reducing health disparities 34 building trust through engaging laypersons from the community as community researchers have the potential to be highly effective in reaching individuals 5 who may not otherwise be willing to participate in traditional methods of research laypersons in the role of community or peer researcher have been engaged in various cbpr studies with great success 6 7 8 9 engaging locals are particularly beneficial in studies where cultural sensitivity is vital 1011 and most importantly there may already be a level of trust established simply by virtue of having a shared experience this paper examines the use of a communityengaged methodology house chats to engage residents in an informal discussion about obesity with others in their community whom they trust and within the comfort of their home or other social setting house chats were specifically designed to address the mistrust community members may have with outsiders who want to study their community furthermore house chats builds the capacity of laypersons to facilitate informal group discussions among their peers and at the same time begin a focused exchange about a subject that may not often be discussed at length house chats are similar in format to kitchen table conversations that have been used as a tool to engage groups in an informal manner with others who invoke trust 12 kitchen table topics can range but usually focuses on engaging the community around issues that may be potentially sensitive health related or political concerns 1314 the main thread however is that the format of the kitchen table conversations provides an informal forum to discuss topics which can be sensitive and moreover the kitchen table approach sets the tone for colearning and it can build momentum for change since it is a bottom up approach to engagement 12 13 14 defining obesity as a concern petersburg is an independent city in virginia just south of the states capital richmond it has a total population of 32420 with the majority being african american 1516 according to the robert wood johnson foundations 2015 county health rankings petersburg is ranked 131 st of the 133 counties in virginia for overall health outcomes including quality and length of life 17 obesity is a major public health concern with adult obesity in petersburg at 36 8 higher than the virginia average 1718 prior to the start of the we project various community meetings were held with residents providers and government officials and it was at these forums that attendees themselves determined that obesity should be the focus of the we project and posited correctly that obesity is a pathway to many other chronic illnesses house chats as a communityengaged research methodology house chats are a novel approach used in the wellness engagement project to ensure grassroots engagement and input about obesityrelated challenges house chats are informal group conversationschats about a topical issue conducted in an informal neighborhood social setting usually in someones home they are similar to focus group discussions with two important distinctions house chats are conducted in a home setting and are facilitated by a trusted neighbor friend or community member house chats unlike focus groups consists of members of a social network usually all linked to the facilitator who could be a friend neighbor or church member however even more importantly house chats by virtue of who the facilitator is has the potential to reach far and wide into the community or social network of the facilitator and therefore individuals who may not be amenable to attend a focus group discussion will likely be keen to attend a house chat simply because their friend or neighbor invited them house chat leaders have the distinct advantage of not only being able to access different individuals but they also have a wellestablished credibility with their participants that would not readily exist in a focus group in a focus group people gather to provide information in a house chat they also gather because they trust the individual that have assembled them this implicit trust credibility and insider status of the house chat leader or facilitator enables them to access individuals who would ordinarily be difficult to reach and even if they were reached might be highly skeptical and hesitant to share within a focus group these advantages are what distinguish the house chat method as grassroots and it is therefore highly applicable to research within a community setting especially using a cbpr approach similar to a focus group 46 participants are considered optimal another major distinction between a focus group and a house chat is that house chats are planned and implemented by the community member from recruitment to facilitation house chats are a unique way to engage the local community with members of their social network in an informal yet focused discussion about issues that could have great sensitivity and would be best discussed at least initially with other perceived insiders house chats to be considered authentic must parallel usual custom for a social event held in the home and therefore food is served communityacademic partnership the wellness engagement project is an academiccommunity partnership between virginia commonwealth university and pathways inc a community development corporation in petersburg the partnership was started in july 2012 when pathways and the academic researcher developed a memorandum of understanding to use a community engagement approach to engage the community to identify their health priorities as part of a cbpr study the copis were jointly responsible for all aspects of the study the partnership was further supported by a community health leadership council comprised of leaders of key organizations who guided the development of all aspects of the study most importantly the partnership established the petersburg wellness consortium which now serves as the umbrella organization focusing on improving health outcomes in petersburg wellness ambassadors who are community residents have an ongoing role in all aspects of the research including data analysis and dissemination regular communication is essential to ensuring meaningful input and transparency weekly meetings are held with the wellness ambassadors and the academiccommunity research team while monthly meetings are held with the community health leadership council and the petersburg wellness consortium the we project conducted a comprehensive and multimethod needs assessment in petersburg which included asset mapping conducted by youth focus groups key informant interviews house chats and a communitywide survey to inform the development of a pilot intervention to reduce obesity this paper reports on the house chats research design residents as house chat leaders building capacity and harnessing the strengths of residents were an essential component of the we project there were two different groups of residents who facilitated the house chats first wellness ambassadors who were engaged in all other aspects of the overall needs assessment including the house chats was were hourly employees and assisted with developing the house chat questions and the implementation protocol for this new method second house chat leaders who were engaged only to assist with the house chats they received a stipend for purposes of this paper we will refer to individuals from both of these groups as hcls and will refer to was only when it pertains to their overall role beyond the house chats we received institutional review board approval for the house chat study which included approval for was and hcls to recruit for and facilitate the house chats furthermore all was and hcls completed irb approved ethics training 19 recruitment hcls were recruited using multiple methods including the networks of various community partners health fairs flyers social media and word of mouth hcls completed an online application which included questions about demographics community involvement health and wellness commitment and anticipated challenges seeking community input hcl were representative of the larger community as well as of certain groups that we wanted to reach such as men and the younger demographic accordingly we recruited 15 hcl six who were between 2030 years of age of these nine were men and 6 women and two of the 15 lived in subsidized housing training hcls attended two intensive training sessions with another follow meeting up after each house chat the first session provided an overview of the we projects goals needs assessment activities already completed and hcls completed the irbapproved cirtification ethics training 2021 in addition ethical dilemmas associated with collecting data from members of their own social networks were highlighted as well as potential challenges associated with being a layperson involved in the research process the second session covered the basic components of the house chat such as recruitment questions use of the data debriefing reports and next steps of the we project trainees completed several mock house chats which were very helpful once a hcl confirmed their house chat date the research coordinator met with them to provide refresher training and a toolkit after completion of each house chat the hcls debriefed with the research coordinator and all was debriefed at the monday night meetings with the research team recruitment of house chat participants hcls recruited members of their social network and participants had to be petersburg residents 18 or older to avoid oversaturation by family members in a house chat the was decided that no more than two family members could be in the same group though an exception could be made if the members were from two different generations or from different households implementation hcls were provided with a house chat toolkit which included the protocol irbapproved verbal consent script conversation guide community survey to be completed at the start of the conversation hcl debriefing questions 10 gift cards for each participant a signature sheet recording receipt of the gift card digital recorder batteries and a checklist hcls were also provided with a 50 stipend to purchase a meal or refreshments with the caveat that it should be a fairly healthy meal all house chats were audio recorded with permission during the design phase several was expressed concerned about recording the conversation and feared that houseguests would not agree to be recorded however no one refused to be recorded although in debriefing the hcls recounted that in some cases exchanges became more personal once recording ceased and food was served research questions the was assisted in the development of the discussion guide which explored the following questions 1 perceptions about obesity 2 what is considered a healthy diet 3 what makes it difficult to be healthy 4 reasonable changes people could make to improve their diet and increase physical activity 5 things people could do personally to help the family become more physically active and 6 advice for the we project to create a culture of health and wellness fidelity checks hcls and was reported back on their experiences in the weekly research team meetings in addition to their written debriefing reports six hcls were selected for telephone debriefing interviews data analysis procedure as a validity measure and method of member checking the hcls provided a verbal summary to the participants at the end of each house chat after the house chat the hcls completed a debriefing report which assessed 1 setting 2 number and sex of participants 3 relationship of participants to hcls and where recruited 4 level of input 5 if participants shared openly and freely 6 confidence in role as facilitator and 7 if anything important was shared after recording concluded additionally each hcl provided a written summary of each question while all house chats were recorded due to the volume of data none were transcribed two research assistants followed a rigorous and timeconsuming process by listening to each recording several times the process of coding was very similar to what is described by researchers who have coded from audio recordings 22 first the coders completed executive summaries for each of the house chats using a 4point likert scale the ras recorded to what extent 1 participants shared openly and freely 2 hcls appeared confident in role of facilitator 3 hcls kept discussion focused 4 hcls ensured that all participants participated 5 hcls created a comfortable informal atmosphere and 6 if the main points in the hcls debriefing report matched the recording they also recorded using a yesno response if the hcl tackled every question during the house chat finally the ras provided a summary of the key points discussed for each question based on the audio recording all closeended data were entered into spss v21 open coding process the session recordings were used as a reference and validation tool to compare hcls debriefing reports with the audio recordings two research assistants listened to the first ten recordings and utilized an open coding process 23 whereby codes were developed directly from the data the codes identified as most central or reoccurring were grouped together in an a priori code list which was used to code the remaining session recordings upon completion of the coding process the resulting list of codes underwent thematic analysis 24 specifically reoccurring or dominant patterns of codes in addition to codes that provided rich insight into our research questions were used to generate overarching themes coders also transcribed brief quotes that were illustrative of a particular theme 22 the open coding procedure allowed codes to emerge directly from the participants responses thereby ensuring the themes emerged from their responses as well discrepancies were resolved by listening to the audio recordings results context hcls held 34 house chats with 176 participants over four months participants were recruited from family members neighborhood church community organizations friends and fraternitiessororities hcls invited a wide range of participants to the house chats the majority of hcls either agreed or strongly agreed that they considered participants as being open and honest during the house chat similarly in 79 of the sessions hcls either strongly agreed or agreed that they felt confident in their role as facilitator in 38 of the house chats hcls indicated that important information was shared or discussed after the recorder turned off the information included requests for more information about the we project how to become a wellness ambassador how to become more involved in their neighborhood offered more suggestions for how to improve health in petersburg and the effect of mental illness on physical health furthermore a few of the participants shared their personal health issues and the role of some churches in contributing to unhealthy eating major themes perceptions of weight first the majority of participants concurred with the thoughts expressed at the initial community meetings that obesity was a major problem in the city however some emphasized that obesity was not a problem unique in the city and in fact suggested that the city has more serious problems to contend with such as unemployment and poverty participants held strong views about the difference between being overweight and obese overweight was considered when a person was larger than what the mainstream expectations were of the ideal weight less of a health risk compared to being obese and highly influenced by culture and environment including access to healthy foods most of the participants indicated that being obese intimated a lack of control and is accompanied by serious health issues they also stated that people who were obese offered suffered social stigma as well as depression barriers to engaging in physical activity there were several key themes that emerged as barriers to engaging in physical activity participants most frequently expressed lack of personal commitment as the major barrier to physical activity many participants shared that the multiple demands of their daily lives made it very challenging to have any physical activity program furthermore the lack of both personal and community resources to support physical activity was noted as a barrier as were neighborhood conditions including a lack of access to safe walking paths unsafe neighborhoods the threat of crime as well as neighborhood dogs finally a few participants mentioned that technology distractions extreme weather conditions and the lack of family support are also barriers to engaging in physical activity barriers to healthy eating the major barrier to making healthier food choices were due to financial constraints most participants indicated that buying healthy food is expensive and that in general their environment does not support healthy eating supporting this theme many participants indicated that there was an unhealthy food bombardment in their community in that unhealthy food was highly accessible and reinforced with billboards and constant commercials about inexpensive unhealthy fast foods similarly participants frequently mentioned the lack of access to healthy foods and moreover indicated that healthy food stores were mostly available in the richer and better part of the city participants also indicated that many of their traditional foods served at family or church gatherings were fried and contained high levels of sodium andor sugar finally other barriers that were discussed by some included the lack of personal motivation demanding daily lives and that healthy food tasted nasty increasing physical activity when asked to identify strategies to increase physical activity most participants indicated that it was essential that the activity be perceived as being fun participants indicated that developing programs that are family based and available community wide would increase the prospect that families would become more active would also serve as motivation for others in the community and would have the additional benefit of promoting accountability and citywide support for behavior change a large number of participants highlighted the significance of setting reasonable expectations for increasing physical activity by introducing small changes finally participants emphasized the need to plan and set aside time for physical active which is consistent with previously identified barriers of lack of time and scheduling concerns suggestions for the pilot intervention one of the primary reasons for the house chats was to seek input from residents on the components of a successful pilot intervention to improve health and wellness the themes that emerged provided a blueprint for the development of the pilot intervention the majority of participants emphasized the importance of providing education about nutrition and cooking healthy meals with the caveat that it should be handson interactive and free the importance of hosting community wide health related events were also a popular suggestion similarly the need for role models and hearing testimonies of people who have been successful in their healthy journey was also regarded as important strategies to create a healthier community participants indicated that the we project should use a holistic approach that is culturally and contextually relevant and it was essential take into account the racial composition of the city include all generations and address the importance of mental health the importance of establishing partnerships was highlighted especially with the school system participants reiterated that it was critical to address access to healthy foods as an integral part of creating a healthier community lastly it was advocated that the language about reducing obesity has to be framed in a positive manner so that individuals do not feel judged discussion laypersons were highly effective in recruiting grassroots community members and the house chats proved to be a successful method for collecting qualitative data in a nonintimidating informal conversational setting most importantly this method allowed the research team to engage residents who may have been impossible to reach or at the very least highly skeptical of traditional research methods such as focus groups the social camaraderie and the use of a neighborhood facilitator provided participants with the opportunity to share their thoughts with others whom they perceive as insiders not only to their community but also to their social network moreover meeting with participants in their physical domain was a critical feature of the house chats as well as building the capacity of laypersons to be community researchers in their own neighborhoods although no participants objected to the house chats being recorded there were a few reports that conversations became more frank after the recorder was turned off suggesting that despite the familiar surroundings participants were aware that the conversation was recorded for research purposes or it could be that after the recording stopped the conversations became more unstructured allowing for less guarded responses future research needs to explore innovative and grassroots methodologies to ensure participation at all levels while still maintaining research integrity and fidelity strengths and limitations there are several limitations worth noting respondentdriven sampling used in the house chats is largely dependent on the characteristics of the hcl conducting the outreach however the hcls were diverse on a range of criteria including neighborhood locations age and sex furthermore some of the hcls were unemployed retired or attending college in an attempt to maintain the informal dynamics of the sessions we did not collect any demographic andor other personal information from the participants future research using house chats might consider the degree to which the methodology is fitting for various diverse andor underserved populations another limitation of this study is that open coding was conducted without the use of transcriptions although the two coders when coding the audio recordings followed a systematic process the lack of transcriptions must be noted as a limitation of the data analysis process future studies using the house chat methodology should use the standard procedure of transcribing the audio recordings to strengthen the validity of the findings despite the limitations there are also notable strengths in the use of this novel methodology including how it enabled access to a more representative sample and the collection of valuable data to inform our intervention within a relaxed atmosphere with communityinsiders thereby enhancing the likelihood of obtaining valid and candid responses key themes that emerged which directly informed our intervention plan included including the entire family using a small changes approach addressing access and environmental barriers incorporating experiential learning activities addressing motivation and values changing social norms and working to create a culture of health and wellness communitywide lessons learned we learned that not everyone has an extensive social network or may be comfortable hosting a house chat the size of the social networks of the hcls varied therefore requiring creative strategies to tap into other networks including asking friends to invite members of their social network to a house chat or hosting a meeting at a friends house with members of their network initially we planned to have the was conduct all the house chats but this proved challenging since they were also involved in other aspects of the needs assessment and some of the wa had limited social networks we learned that recruiting laypersons specifically to conduct house chats proved successful especially once we started recruiting hcls to meet specific demographic requirements hiring additional laypersons in the role of hcl not only expanded the types of social networks we were able to access but it also relieved the wa from the pressure of being solely responsible for conducting house chats furthermore we learned that the house chats could be an unexpected recruitment strategy as it resulted in at least three participants becoming was and three who decided to become hcls conducting house chats also proved to be effective at generating more awareness and support for the we project nonetheless we learned that the house chat methodology required extensive logistical management such as hiring and training hcls coordinating schedules collecting data conducting debriefing meetings and providing constant oversight to ensure the integrity of the research process some house chat meeting dates would change or the coordinator would be informed that the hcl was able to schedule an impromptu house chat and therefore needed to be provided with session materials including the stipends hcl will generally invite participants who share similarities with them in terms of age sex race religion and social affiliations therefore who the hcl are as well as their level of social engagement will largely determine who the guests will be and this an important consideration in recruitment some hcls were very effective in hosting several house chats while other members had a much smaller social network to draw upon regardless of varying recruitment abilities laypersons in the role of facilitator are able to actively engage members of their network in a focused conversation about obesity performance in this role will vary however less likely to vary is the trust and comfort level the participants are likely to have in the hcl given the implicit trust there are important considerations involving privacy and confidentially as house chats could include several participants who may know each other the usual research safeguards must be practiced including training and debriefing the hcl and explicitly stating to participants the purpose of the study and how information will be used while the intent of house chats is to be conducted within a relaxed atmosphere facilitated by a community member that is implicitly trusted it is still a method of data collection for research purposes therefore it is of the utmost importance in training the hcls to be sensitive to unanticipated issues of confidentiality and privacy the hcls credibility is a key component of this grassroots method and likely enhanced the studys credibility the localness of the hcls their tacit knowledge of the community and connections with participants not only yielded social capital 25 but it also has the potential to create a level of awareness amongst peers about topics that are ordinarily not discussed amongst them furthermore unlike in a focus group the house chat participants are more likely to have ongoing contact with the hcls since they are part of their social network and this association may increase the prospect that participants or the hcl will follow up with each other both about the topic and the research we highly recommend using this approach specifically in cbpr studies where there may be a higher likelihood that the hcl could remain engaged in the project and will therefore be in a position to provide ongoing updates to participants this approach has strong potential within a cbpr context to build the capacity of laypersons and to reach diverse social networks that may not be reached with more traditional methods our thanks to the wellness ambassadors and house chat leaders for their work in reaching out to their social networks and inviting them to participate in the house chats together everyone did a phenomenal job thanks to joshua beasley rachael beckberman dominic clanton alana frost roger graves ralph hawkins maria johnson talibah majeed elayne mitchell keonte owens yvette robinson john smith teresa smith and ron thompson we would like to thank sarah ochs research coordinator for navigating the many logistical aspects of conducting house chats a special thanks is also due to pamela bingham community outreach coordinator for her diligence in regularly checking in with the wellness ambassadors and providing them with constant support as well as providing the entire research team with more than just the occasional appreciation gift pamela also worked tirelessly in the community to ensure project transparency and follow up we would like to thank several research staff that provided technical assistance in the preparation of this manuscript they include research coordinator stacy west and graduate students avina ross and especially kyu kang finally our heartfelt thanks to the members of our community health leadership team for their expert guidance strong support and valuable input on all aspects of the study the members of the chlc are tiffany cox dr alton hart oliver jenkins florence jones clark debbie jones valerie liggins ryan massenburg andrea matthews natan mckenzie mike roberts and dr novella ruffin the content of this manuscript has not been published elsewhere the work is and will not be submitted for consideration to any other publication while under consideration by pchp the research reported in this paper was supported by national institute of minority health and health disparities r24md008128 the terms of this support has been reviewed and approved by virginia commonwealth university virginia commonwealth universitys institutional review board has reviewed and approved this study

backgroundthe wellness engagement project is an academiccommunity partnership developed to engage the community to inform the development of a pilot intervention aimed at promoting healthy eating and physical activity among residents of petersburg virginia objectivesto implement house chats as a novel methodology for engaging community members in focused discussion about obesity exercise dietary intake and barriers to health methodswe recruited and trained laypersons as house chat leaders to host informal group discussions about obesity with members of their network in a social setting following predetermined questions resultshouse chat leaders hosted 34 house chats with 176 participants over a period of four months conclusionsthe house chat proved to be a highly successful engagement strategy which allowed access to respondents who may not have participated in a traditional focus group discussion

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mental health and wellbeing are critical in determining important outcomes in later life such as physical health vulnerability to disease and mortality research supports the multidimensionality of mental health and wellbeing indicators particularly in distinguishing between positive and negative facets and their predictors for instance in recent longitudinal findings positive and negative affect demonstrated differential groupand individuallevel trajectories as well as differing predictors prior to age 70 negative affect decreased however after this age it tended to rise in contrast with age positive affect tended to exhibit decline given the relative paucity of mental health research with individuals in very late life the primary objective of the current paper was to identify predictors of three mental health and wellbeing indicators in an effort to better understand potential contributors to mental health and thus targets for prevention and intervention efforts based on prior empirical and theoretical work we expected that individual resources including cognition functional ability and personality as well as social resources would contribute to mental health outcomes among the oldest old haynie berg johansson gatz zarit 2001isaacowitz smith 2003long martin 2000martin martin 2002 the three indicators of mental health and wellbeing examined in the current paper are important throughout older adulthood and are likely to exhibit synergistic effects particularly for negative mental health indicators negative affect in particular appears related to psychological distress and depression chang sanna 2001 prior work wichers et al 2007 suggests that those who are genetically predisposed to depressivity are more likely to exhibit negative affective reactions to minor stressors in everyday life on the other hand positive affect is seen as a protective factor in older adults being associated with optimism adaptive coping responses and lower depression independent of negative affect personality is one dimension shown to predict positive and negative affect specific personality traits such as extraversion have been linked with positive mental health outcomes such as positive affect whereas greater neuroticism tends to predict poorer mental health outcomes such as anxiety and negative affect prior work with older adults revealed that extraversion was predictive of positive affect in men and neuroticism was a strong predictor of negative affect in both men and women even after controlling for physical health in addition to an underlying mechanistic link personality traits can more practically affect interpretation and reporting of affective and mental health symptoms including overreporting of symptoms by individuals compared to observers in addition to affect prior research ties personality to the mental health outcome of loneliness among oldestold parents and their adult children individuals with anxious personalities were more likely to be lonely on the other hand those high in extraversion reported decreased loneliness among the oldest old research suggests a link between greater neuroticism and increased loneliness psychometrically loneliness is highly correlated with personality and mood measures but also strongly related to perceived quality of social support in terms of cognition extant literature reports a link between cognitive abilities and mental health in a study of older adults conducted by haynie and colleagues higher cognitive performance as assessed by the wechsler block design test was related to less negative affect other work suggests that cognitive status may be related to loneliness among older adults however the effects varied across cultural context additionally demographic and functional indicators are also important predictors of mental health in older adulthood specifically institutional residence ethnic minority status decreased ability to perform activities of daily living and lower subjective health are associated with poorer mental health outcomes while biological and social risks tend to increase throughout older adulthood the prevalence of negative mental health outcomes such as depression are comparable or lower compared to early adulthood this finding indicates that additional factors may be instrumental in protecting older adults from negative mental health outcomes thus the current analyses were employed to investigate the ability of individual and social resources to predict positive and negative affect and loneliness consistent with prior studies we expected institutional residence increased neurotic tendencies fewer social resources and diminished cognitive and functional abilities to predict loneliness and negative affect whereas extraversion greater cognitive ability and more social resources were expected to predict increased positive affect method procedure and participants participants included octogenarians near centenarians and centenarians who took part in the most recent georgia centenarian study data collection the study was approved by the university of georgia institutional review board prior to participation the study was explained to participants and informed consent was obtained octogenarians and centenarians were individually tested in their place of residence the current analyses rely on selfreport data as a result the included participants represent a subset of study participants all of whom scored 17 or greater on the minimental status exam and had the opportunity to be interviewed on mental health questions given an increased prevalence of sensory impairment and its impact on mmse scores along with generally low levels of formal education among this cohort a lower minimum cutoff was chosen selecting from the total sample of 375 this criterion yielded a subsample of 157 adults composed of 63 octogenarians and 94 centenarians and near centenarians who were eligible to complete more cognitivelydemanding assessments those 132 participants with complete data on the independent variables were selected for analyses 55 octogenarians and 77 centenarians within this subsample centenarians were more likely to be female living in a nursing or personal care home and widowed measures participants completed measures of mental health demographics and functioning cognition and social functioning and personality table 1 depicts sample averages on these key variables and table 2 depicts the bivariate correlations between variables mental health outcomesloneliness was assessed via the 10item short form of the ucla loneliness scale each question was responded to using a fourpoint scale where 1 corresponds to never and 4 corresponds to always a total score was created by recoding responses to the positively worded items and then summing together scores on the 10 items thus higher scores indicate greater loneliness observed scores ranged from 10 to 32 cronbachs alpha for the georgia centenarian study pilot sample on the 10item version of the scale was 81 the bradburn affect balance scale was used to assess positive and negative affect this 10item scale requires participants to indicate the extent to which they had experienced presented descriptors during the past few weeks including uneasiness boredom and excitement a 4point response scale was used which ranged from not at all to often higher scores represent greater endorsement of the respective affect in the current sample scores ranged from 5 to 18 for positive affect and 5 to 15 for negative affect reported internal consistency for each scale is above 80 demographics and functional indicatorsage sex residential status and ethnicity were included in the analyses residential status was collapsed to distinguish private and institutional residence in a personal care or nursing home perceived ease in completing desired activities despite health troubles was assessed via a single 3point likert item higher scores indicated greater perceived ease ability to perform activities of daily living was assessed via 13 items from the older americans resources survey items responses ranged from 02 and higher scores indicate greater ability to perform adl tasks cognitionthe severe impairment battery was used as an indicator of global cognitive ability the scale assesses nine cognitionrelated domains of functioning and higher scores indicate better functioning the behavioral dyscontrol scale was included as an indicator of executive functioning social functioning and personalityfour items from the oars were used to assess the availability of social resources higher scores indicate greater resources the 12item social provisions scale was used to gauge the nature of social relationships among the oldest old and their partners a total score was used which reflects individual item pairs gauging alliance guidance integration attachment worth and nurturance higher scores indicate endorsement of these domains items from the neo fivefactor inventory a short form of the neo personality inventory revised gauged personality trait endorsement on a 3point scale given prior research relating extraversion and neuroticism with mental health we focused on these scales observed scores ranged from 11 to 11 on extraversion and 12 to 10 on neuroticism α 74 89 results hierarchal linear regression analysis was employed to assess the role of cognition personality and demographic and functional indicators in predicting positive and negative affect and loneliness three steps of predictors included demographic and functional variables global cognitive ability and executive functioning and personality and social resources analyses were conducted using spss version 150 and an alpha level of 05 was adopted a summary of the regression analyses are presented in table 3 for both negative mental health indicators loneliness and negative affect only inclusion of step 3 was a significant addition to the model the models accounted for 36 and 41 of the explained variance in loneliness and negative affect respectively in terms of personality predictors greater neuroticism predicted both increased loneliness and negative affect greater perceived social resources and provisions were related to less loneliness cognitive indicators were not predictive of loneliness however greater executive control as assessed by the bds was related to decreased negative affect the analysis examining predictors of positive affect revealed that both steps 2 and 3 added to the predictive utility of the model the addition of step 2 revealed a significant effect of global cognitive functioning on positive affect better cognitive functioning was related to increased positive affect the effect however was not retained once step 3 predictors were included in the model addition of the third step indicated a relation between extraversion and social provisions with positive affect the final model accounted for 33 of the explained variance in positive affect discussion in the current study we investigated the role of selected indicators of cognition and personality in predicting loneliness and positive and negative affect in a sample of oldestold individuals personality emerged as a strong and consistent predictor of each mental health outcome however the particular influential personality component varied according to the nature of the mental health outcome greater neurotic tendencies were related to increased negative affect whereas higher levels of extraversion predicted increased positive affect the importance of personality characteristics on these particular mental health outcomes may not be surprising given the social implications of neurotic and extraverted tendencies for instance personality may serve to elicit or hinder social support to account for such relations we included indicators of social functioning in the analyses consistent with expectations perceptions of greater social resources which reflect the availability of partners were related to decreased loneliness the quality of social relationships was also important greater social provisions or the perception of more satisfying relationships with others was related to decreased loneliness and increased positive affect within this sample of cognitively wellfunctioning individuals cognition played a relatively small role in predicting our three mental health outcomes executive functioning as assessed by the bds was related to decreased negative affect global cognitive functioning as reflected in the severe impairment battery was a significant predictor of positive affect however this relation was no longer significant once social functioning and personality were entered into the analyses this result may not be surprising given that the sib assesses abilities needed to effectively carry out social relations similar to our speculation regarding the nature of personality and its implications on social functioning cognitive abilities have also been related to other mental health predictors such as perceived social support taken together these findings suggest that researchers and clinicians may be well served to consider potential mediators of the relations between personality cognition and mental health in very late life social context appears to be one fruitful path given the crosssectional nature of our data we cannot disentangle the effects of survivorship on our results future work should be aided by longitudinal investigations which can examine the likely complex causal relations between multiple indicators of personality cognition and mental health bivariate correlations between study variables 1 2 3 4 5 6 7 8 9 10

objectivesaffect and loneliness are important indicators of mental health and wellbeing in older adulthood and are linked to significant outcomes including physical health and mortality given a large focus on youngold adults within gerontological research the primary aim of the present study was to examine the ability of individual and social resources in predicting affect and loneliness within a sample of oldestold individuals

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introduction the effects of social relationships and social support are well documented in a large number of studies social networks or social support exchanges in supportive social relationships are related to better health for example those with more social networks have a lower risk of mortality 1 morbidity 2 functional disabilities 3 4 5 and cognitive impairment 6 when people interact something is exchanged namely social support in other words social support is embedded in social relationships 1 studies have also reported the association between social support and cognition seeman et al 7 reported that emotional support was a significant predictor of cognitive functioning at the 75year followup using macarthur studies of successful aging data another 12year followup study 8 demonstrated that baseline exposure to emotional support was independently associated with a better minimental state examination score at followup according to a systematic review of 19 longitudinal studies that investigated the association between social relationship factors and incident dementia not network size per se but lack of social interaction seems to be associated with incident dementia 6 however given the nature of social support cultural or gender factors cannot be ignored when assessing its effect on health a study in the united states 9 demonstrated that gender moderates the relationship between social support and cognition higher levels of emotional support are associated with better cognition only among females support sources are also important factors to consider in general studies in western nations have reported that support from a wide variety of sources including friends or neighbors can be beneficial for the health of elderly populations 1 on the contrary studies in the east have reported the relative importance of family support a crosssectional study in china 10 demonstrated that family support is the strongest predictor of cognitive function among older persons whereas support from friends was not cheng et al 11 suggested based on their conclusions in another crosssectional study in china that interactions with friends are less wellbeing enhancing in asian societies compared with their western counterparts the authors speculated that in societies where social harmony and reciprocity are valued like those across asia the cost of seeking help from others especially from nonfamily members might be higher compared with more individualistic societies fiori et al suggested that the relative importance of filial duty in asian cultures might also explain the result 12 thus the association between social support and cognition might be different depending on support sources in asian societies such as china korea and japan compared with their nonasian counterparts however as far as we know few studies have examined the longitudinal effect of social support on dementia in asia only one study in taiwan reported that along with other risk factors such as physical activity or depression social support is related to late life cognitive decline 13 saito et als study demonstrated the relative importance of diverse social networks in preventing dementia however the study did not consider sources of support in addition gender was treated as a covariate and gender differences were unclear 14 the purpose of this study is to assess the effect of social support on incident dementia taking into consideration support sources by gender our hypothesis was that the protective effect of social support on dementia differs by source and gender and that the effect of family support would be stronger compared with nonfamily support materials and methods the present study is part of the aichi gerontological evaluation study project 15 the ages project is a communitybased prospective cohort study in japan in which investigators evaluate factors associated with incident functional disability or dementia among noninstitutionalized older people aged 65 years old or above in the baseline year of 2003 questionnaires were sent to a random sampling of communityliving older adults aged 65 years or older in six large municipalities and a complete census of four small cities the response rate was 521 detailed descriptions of the project and questions on the survey have been published 16 after excluding those with incomplete data on sex and age 15313 people were introduced in the cohort and followed for about 10 years from 1 november 2003 to 28 march 2013 we obtained information regarding incident functional disability dementia death and relocation of participants from the longterm care insurance system database maintained by municipalities for the analyses we eliminated those with limitations in basic activities of daily living such as using the toilet bathing or transferring at the baseline year of 2003 this procedure left 14088 people or 92 of the total sample of this cohort study participants were comparable to entire older japanese populations in terms of age and sex 15 brief description of japans ltci system japans ltci system is a governmentoperated national insurance system for longterm care and was introduced in april 2000 to entitle every japanese person aged 65 years and older with functional limitations or dementia to care in basic activities of daily living 17 in this system certification of longterm care needs is based on an evaluation of each applicants degree of physical and mental disability determined by a homevisit interview and a diagnosis from a primary care physician a municipality certification committee determines the eligibility for receiving services 17 as receipt of benefits under this ltci system is on an application basis some people do not receive benefits under the system for various reasons such as the availability of family members to provide care or financial burden to minimize such bias we asked about basic activities of daily living such as using the toilet bathing or transferring in the 2003 survey and then excluded those already functionally impaired at baseline incident dementia incident dementia was ascertained when study participants became eligible for japans public ltci system level ii or higher on the index for the evaluation of care needs for people with dementia the index was developed by the ministry of health and welfare based on observations of symptoms and behaviors that cause daily life impediment and degradation of cognitive functions along with communication difficulty this index was validated using the mmse and revised hasegawa dementia scale the correlation coefficients with each scale were 0744 and 0735 respectively indicating strong correlations with clinically used instruments 18 insurance data were provided by insurers per the study agreement with the ages project 16 social support to elucidate social support we asked respondents about the five types of perceived social support with respect to persons in three social support sources coresiding family familyrelatives living apart and friendsneighbors coresiding family refers to spousepartner children or others living in the same household familyrelatives living apart refers to adult children siblings or others not living in the same household the types of support were emotional instrumental and appraisal the act of listening to concerns and complaints was regarded as emotional support and that of looking after when sick in bed for a few days as instrumental support appraisal support was elicited by asking do you have someone who acknowledges your existence and value these types of supports were often used in previous research studies 116 answering categories for these social support variables were coded dichotomously as support available and no support available covariates age and health status are important confounders when assessing the relationship between social support and health 119 number of illnesses was ascertained by the question are you currently receiving any medical treatment and if so for which illnesses for analyses we calculated the number of illnesses treated as a continuous variable we adjusted for depression as well as depression coexists with or predicts dementia 20 depression was assessed by the 15item geriatric depression scale an instrument to screen depression among communityliving older persons 21 the score was transformed into a dichotomous variable subjective cognitive complaints predict dementia among the elderly 22 thus we asked respondents the following three questions do you often get into trouble when you leave your belongings behind somewhere do you often get times or places confused and do you often forget things that happened recently the possible highest score was three suggesting more cognitive impairments as living arrangement is strongly associated with health 19 we adjusted for its effect as well by stratifying those living alone and those living with someone else we adjusted for marital status as well since a small number of respondents did not live with their spouse even while they were married probably owing to hospitalization or institutionalization of their spouse engagement in community activities was ascertained by asking respondents about the number of community groups they participated in such as sports hobby or local associations as such participation is protective against dementia 20 health behaviors such as smoking status daily physical activity alcohol consumption and education were also considered in the model statistical analyses as studies have indicated that the association between social support and health differ by gender 1 cox proportional hazard models were employed stratified by gender to assess the association between baseline social support and incident dementia those who died or moved away from the study site during the followup period were considered as censored cases to test if the effects of social support from each source were independent of the influence of others we entered social support in the model along with other covariates stratified by support source as our main aim was to study the relative effect of social support social support variables were aggregated to create social support scores by support source moreover we tested which support type was the most beneficial when coming from the same support source the correlation coefficients of social support variables were as high as 0705 for example between providing instrumental support and receiving instrumental support for family members living together as such we constructed three models stratified by support source to avoid multicollinearity then we investigated the association between each social support and dementia we used spss 210j for statistical analyses a pvalue of less than 010 was considered marginally significant and a pvalue less than 005 was considered statistically significant ethical issues the study protocol and informed consent procedure were approved by the nihon fukushi university ethics committee the study was conducted in compliance with the fifth revision of the declaration of helsinki results table 1 shows baseline characteristics by gender during the 10year followup 146 of men and 187 of women developed dementia men were slightly younger and participated in more community groups but smoked and drank more alcoholic beverages more women lived alone and had more cognitive complaints than did men in addition women were significantly more depressed and had more illnesses table 2 describes social support by type and source as for social support men exchanged more support with coresiding family members whereas women had more ties with familyrelatives living apart or friendsneighbors when subdivided by sources men exchanged more emotional and instrumental support with their coresiding family and received more appraisal support from all sources than women did women exchanged more emotional and instrumental support with someone outside of their own households namely a family memberrelative who lives apart or friendsneighbors when considering the effect of support sources men benefit more from support exchanges with their coresiding family members as shown in table 3 as for types of support providing support to coresiding family was a significant protector against dementia among men whereas among women providing emotional support to familyrelatives who live apart and receiving emotional support from friends or neighbors were protective against dementia contrary to our expectations instrumental support exchanges with friends or neighbors were risks for dementia among men among women receiving emotional support from coresiding family members raised the risk of dementia whereas providing support to a familyrelative who lives apart and receiving emotional support from friends or neighbors were protective of dementia discussion support tofrom coresiding family using 10year followup data we assessed the impact of social support on incident dementia by sources contrary to our expectations family support was beneficial only for men in our data although we cannot ascertain with whom men exchanged support in the house in the subanalysis 925 of men with support from coresiding family were married this supports the result of saito et als study which found similar associations that among men support from spouse was an independent protective factor against functional disability 23 in that study lack of social support explained 244 and 158 of the excess risk of disability among men living alone and those living with nonspousal cohabitants respectively this also is in line with a review that indicated that men tend to report their spouses as confidants whereas women do not 119 cognitive benefits of support from coresiding family members for men could also be attributed to enhanced social roles or selfefficacy by providing support to their spouse another reason for such difference is the difference in the nature of support they receive in addition to womens longer life span men tend to provide more practical help such as bringing them to hospital whereas women tend to provide more essential help in daily living such as cooking or cleaning the house and giving emotional assurance this means that men with care needs might live without applying for insurance benefits as long as their spouse can provide essential care this might lead to delayed diagnosis of dementia among men among women receiving emotional support from coresiding family members was a risk for dementia goldzweig et al reported that women often feel guilty when they cannot perform household chores 24 such feelings of guilt might undermine their selfimage and lead to poorer mental health a risk factor for dementia a cross sectional study in the united states demonstrated a negative association between social support and cognition in which among older persons greater social support was associated with poorer nonverbal memory and response inhibition suggesting their care needs 25 marital benefits among men might partly explain the result a study reported that married men reported significantly higher levels of spouse support compared with married women 24 support tofrom family living apart in our study social support from family or relatives living apart had no significant effect on cognition in both genders except for the provision of emotional support among women a study in china demonstrated the importance of extended family for the wellbeing of older persons especially when support from immediate kin was not available 12 in japan more adult children live separately from their parents once they get married when needs arise they take care of their older parents thus the availability of support from family or relatives living apart might indicate the actual care needs among older parents another explanation is that the nature of support might be important for older persons health a review of studies reported that receiving emotional support from kin members raised the wellbeing of older persons whereas receiving instrumental support did not when the quality of relationships was low 1 because kin relationships are not easy to terminate even if the quality is poor this might lead to feelings of guilt or dependency and even reduced autonomy a study using the english longitudinal study of ageing data with a 10year followup period reported that positive social support from children reduced the risk of dementia whereas negative support increased the risk among persons aged 50 years and over 26 although we cannot assess such an effect in our study due to the lack of related variables quality rather than quantity of social relationships might be important for cognitive health support tofrom friends or neighbors among men instrumental support exchange with friends or neighbors was a risk for dementia psychological factors in part explain this result studies have reported that social relations lacking in mutuality often undermine the selfimage of the support recipient receiving support from nonfamily members could be considered a shame or threat to mens masculinity goldzweig et al reported mens lower ability to use social support compared with women based on their observations that despite receiving more support men tend to report more psychological distress in the face of illness 24 also men are less likely to seek help for physical and psychological problems 27 another possibility is gender differences in social relations in japan nonfamily support is mainly provided by same gender individuals 28 male friends are more likely to advise friends to receive treatment with deteriorated cognition while female friends tend to provide essential help and emotional assurance so that those in early stages of dementia could continue living in the community in the subanalyses we assessed the characteristics of men who exchanged instrumental support with friends or neighbors they were more likely to be married and living with someone else in addition more than 90 of them reported that they exchanged support with coresiding family thus the likelihood of dementia among men with instrumental support from their friends or neighbors could be partially explained by their deteriorated cognition that could be easily noticed by others among social factors community engagement was more strongly associated with lower incidence of dementia among women while for men being married was a stronger protector against dementia this is in line with studies in western nations in which men received emotional support mainly from their spouses whereas women received more support from their friends and relatives or children 629 a previous study with the same dataset reported a similar association in which broader social networks were protective against incident dementia among women 14 this may also be explained by the replacement function of social networks women often live longer than men and cannot rely on their husbands when needs arise in fact in our previously reported study finding women living alone had more contacts with outside nonfamily members 30 also relationships with nonkin members such as friends or neighbors are mostly voluntary and based on mutual trust and love meaning more positive support 31 in addition to interact with nonfamily persons one must go out of ones own home which could lead to receiving more physical and cognitive stimuli in daily life strengths and limitations this studys major strength is the use of large insurance data with few missing cases that were maintained by municipalities the present study adds several new findings to those of earlier studies first a longitudinal protective effect of social support on dementia was suggested second different effects of social support by type and source were observed third gender differences were also observed in the association one limitation of this study is the use of a proxy measure for incident dementia as mentioned in the introduction a certain percentage of people do not apply for insurance benefits for various reasons although we eliminated those with impairment in basic activities in daily living and adjusted for baseline cognitive complaints people with undiagnosed dementia might have been included in the study population in addition the presence of a spouse might delay the diagnosis of dementia among men due to spousal support in daily living and lead to misclassification of cases also the representativeness of the population might be an issue when we assessed the tendency of nonresponders those aged 85 years and over and those with lower income were less likely to respond 16 meaning that the risk of incident dementia might be underestimated in this study since incident dementia is higher among those groups 16 another limitation is that only baseline social support was measured as people get older their life space is more likely to diminish and be confined to a narrower network of people also the effect of social support might diminish over time to consider such a possibility we repeated sensitivity analyses with shorter followup periods however hazard ratios did not change much studies have reported that despite the number of social ties diminishing over time among older persons the amount of emotional and instrumental support did not 7 indicating a relatively stable effect of social support nonetheless studies with repeated measurements that can consider changes in social support might be desirable conclusions gender differences were observed in the association between social support and incident dementia support from coresiding family members was protective among men whereas among women no significant effect of social support on dementia was observed considering the gender differences in the association between social support and dementia and the possibility of misclassification of cases the use of objective diagnosis data might be necessary also given the fact that the number of older people living alone is increasing 2 there is a greater need to investigate the effect of promoting social ties with outside family members as men benefit more from support from coresiding family members different strategies might be needed in designing intervention programs for men deteriorating cognitive or physical functions might undermine their selfimage leading to poor health this occurs especially among men who want to be strong and do not want to show their weakness to others 24 in our study appraisal support from someone outside of their own homes was related to a lower hazard for dementia although it was not significant if support is provided with respect or if recipients are given more of a chance to give back support this might preserve autonomy and mitigate the negative effect of receiving support especially among men such support could enhance their selfesteem and compensate for the threat of loss of autonomy from receiving support author contributions cm and ts conceptualized and conducted analyses cm wrote the original draft and prepared the final manuscript ts ms and kk reviewed and approved the content kk administered the ages project and acquired funding for the project program for the strategic research foundation at private universities grantinaid for scientific research and a grant from the national center for gerontology and geriatrics

social support is important for the health of elderly populations however its longitudinal effect on incident dementia is unclear we used the aichi gerontological evaluation study ages project data to investigate the longitudinal effect of social support on dementia onset functionally independent older people at baseline n 14088 in 10 municipalities were followed from 2003 to 2013 using national longterm care insurance system data social support was assessed by the following support sources coresiding family family or relatives living apart and friends or neighbors cumulative incidence of dementia was 146 and 187 for men and women respectively cox proportional hazard models were employed by gender to investigate the association between social support and dementia onset adjusting for age health status health behaviors subjective cognitive complaints depression and other socioeconomic factors gender differences were observed in the association between social support and incident dementia support from coresiding family members was protective among men whereas among women no effect of social support on dementia was observed among other social factors community engagement was protective for women while for men being married was associated with lower incidence of dementia the association between social support and dementia seems to differ by gender when we design programs to promote social interactions among the elderly we need to take into account such gender differences

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introduction navigating healthcare systems and engaging in healthy behaviors can be difficult for those born in the countries they reside in refugees however contend with additional challenges and a myriad of factors affecting their health outcomes in providing some context into what or who constitutes the refugee population the united nations high commissioner for refugees describes a migrant as someone who left their home for a variety of reasons including but not limited to seeking better education work or reuniting with family 1 while a refugee is someone who leaves due to war violence conflict or persecution 2 castañeda and holmes however caution on the limitations of these definitions as they argue w hether a person is identified as a refugee or as some other socially constructed category depends on historical sociocultural political and economic contexts 3 there are nuances and implications for the use of the terms refugee versus migrants in regard to the choice to emigrate these delineations are not necessarily rigid 4 and the notion of choice is one that can be contested given the push and pull factors that cause people to emigrate which for immigrants are often economic with important implications for health and wellbeing according to the unhcr the most recent data from 2018 indicated that there are over 259 million refugees worldwide more than at any time in history 5 as of 2015 the three countries that resettled the greatest number of refugees were first the us who resettled 52 583 refugees second canada who resettled 10236 refugees and third australia who resettled 5211 refugees 6 following these three countries there was norway germany sweden the united kingdom finland new zealand and france 6 the process of resettlement in another country is lengthy in the us for example the process of resettlement takes at least two years and involves intensive medical and security screening by at least fifteen different agencies 7 over 3 million refugees have come to the us since 1975 and resettled in all 50 states 7 once they arrive refugee health screening care access and clinical resources vary among states 8 the official domestic medical screening guidelines checklist by the office of refugee resettlement is strictly physical and assesses cholesterol hepatitis hivaids and tuberculosis status but does not assess any psychosocial aspects of health 9 the us centers for disease control and prevention has twelve additional recommended screening guidelines including mental health which are not mandatory 9 additionally in australia for example from 2014 to 2015 there was an average waiting period of 145 months to receive a refugee visa 6 moreover since 1977 australia has been among the top three countries in the world for refugee resettlement 6 australia accepted the largest number of refugees from 1980 to 1981 with 20795 and from 1975 to 1978 and then from 1984 to 2012 and 20132016 australia accepted less than 10000 refugees per year 6 resettlement in australia also involves medical screening as well as character screening which includes screening of criminal conduct 10 of the individual or family and family they may be reunifying with in the country of resettlement 10 in countries of resettlement health care and social service providers who work with refugees particularly refugee women need to be equipped to work in a culturally safe manner and to be sensitive to their unique needs the existing body of literature focused on aspects of refugee health such as prenatal appointments or mental health among refugee women while this research has been valuable for informing recommendations for best practices with this population it lacked a holistic approach that includes other salient factors that impact womens health postsettlement literature on this topic tends to focus on one specific population and one specific health outcome among refugee women for example marshall et al focused solely on the mental health of cambodian refugees ages 3575 in their study 11 in this article we conduct a comprehensive synthesis of the literature on the topic through thematic review to identify social cultural and environmental factors that affect refugee womens health while we examine the usspecific context the literature covers several different resettlement countries including the us such as australia belgium the netherlands south korea and the united kingdom thus the findings have implications for other nations that resettle refugees this is because as we demonstrate in our review of the literature many factors that influence refugee womens health such as patientprovider interactions and migration history impact health regardless of the resettlement country furthermore resettlement countries have different healthcare systems for example in australia there is a mix of universal public and elective private health insurance in the netherlands the government provides most care through publicly financed health insurance and in the us while there are some programs for children and the elderly most americans have private health insurance and many are uninsured 12 in our review we uncover how different ecological factors impact refugee womens health postsettlement our key research questions were 1 what arenas such as health care social support violence and mental health help or hinder refugee womens health post resettlement and 2 how can the socialecological model framework be adapted to inform implementation of programs targeting refugee women at various levels to address our research questions we conducted a twotier analysis of the literature first we conducted a deductive thematic analysis of the literature guided by a cultural safety lens a cultural safety lens means that providers examine the power dynamic of their relationships with patients as well as participate in sensitive reflections of their interactions with patients 13 second we created an adapted sem model to provide clear framing and recommendations in our discussion section for improving the health of refugee women this article presents information on the background of refugees as well as experiences with violence mental health health care and social support our methodology is fully explicated in the methods section positionality of the authors at the time of writing this article none of the authors were refugees themselves the authors were graduate students undergraduate students and faculty in schools of public health nursing and international studies in departments of communication studies sustainable peacebuilding epidemiology and community and behavioral health promotion most authors were at a large public urban university in the midwestern us they identify as latina black filipina and white authors have served in the peace corps and americorps they worked as nurses including as a sexual assault nurse examiner and three are african immigrant women who conducted research and work with immigrant and refugee populations in the us while this is primarily a literature review positioning ourselves at the time of our writing and this article was key to respecting the agency of refugees and noting our own biases theoretical framework in this manuscript we incorporate a lens of cultural safety cs is distinguished from other perspectives namely cultural competence because it requires healthcare providers to examine issues of power in their relationship to and interactions with patients who have been relegated to the margins of society 13 in the context of cs culture among refugee women is represented by the fluid and dynamic ways in which individuals identify at any given time including but not limited to race gender identity sexual orientation and socioeconomic status we incorporate cs in our review to highlight the need for sensitive reflection among providers serving refugee women the socialecological model the socialecological model of health is crucial to framing this article the cdc notes that in order to prevent and address adverse health outcomes a multilevel approach is key 14 the agency recognizes that t his model considers the complex interplay between individual relationship community and societal factors and allows for organization of the range of factors that put people at risk 14 sem aids us in conceptualizing and understanding the individual interpersonal organizational and community factors that impact health a key assumption of such ecological models is that in addition to individual characteristics social and physical environments impact health and both environments are dynamic and complex 15 another key assumption is that complex relationships organizational and community systems influence one another 15 however sem is itself not a theory nor does it describe the variables of processes at each level expected to be the most influential on behavior 16 sem is a framework and allows us to organize a comprehensive model of the factors influencing health within a population in order to thoughtfully inform interventions 16 sem is also used as an interpretive framework for instance mengesha and colleagues 17 used the framework to identify factors influencing access to health care among refugees and migrants in australia this is what we have done in this literature review we adapted sem for the refugee context by drawing upon two ecological models for displaced persons and refugees one by keygnaert and colleagues 18 and another by wells and colleagues 19 and based on our review of the literature methods we conducted a scoping literature review of the existing literature guided by the sem we restricted searches to google scholar jstor global health pubmed cina hl sociological abstracts and social service abstracts to the years 20092019 and to works published in english prior to initiating the search key themes were identified based on our research questions these themes were refugee health refugee womens health violence social support health care access and successful program models the themes were then organized into three major categories health care access violence and mental health and social support the authors also used citation chaining to identify other relevant information and to cite the original sources of articles we conducted our literature search by including the sem term but this yielded only three relevant results we therefore broadened our search to include articles that did not explicitly address sem but to which the sem framework could be applied and assessed each author reviewed literature on a specific area such as violence faced by refugee women or health care access and these articles were then screened by the lead author we included peerreviewed articles such as literature reviews qualitative studies quantitative studies and conceptual articles articles included both women and men and there was no limit on the age of refugees in the studies we also included books government websites and one professional website for practicing nurses we did not include nonpeer reviewed dissertations newspaper articles or blog posts articles were screened by title and abstract before considering the whole article after removing duplicates a total of 96 fulltext articles and 31 other sources were screened for eligibility in the final analysis we included 52 articles 3 books and 8 other sources results of the 52 articles reviewed 37 focused on the health of refugee women the remaining 15 articles provided were conceptual and provided supporting information on topics such as general information about health literacy among refugees the 37 articles focused on a variety of populations resettlement countries and types of studies such as literature reviews qualitative and quantitative studies regarding the type of study qualitative studies were most common and three of those 26 used a communitybased participatory research approach there were four quantitative studies there were also five literature reviews one metaanalysis and one program evaluation thirteen studies did not indicate the countries of origin of the refugees they worked with including three of the four quantitative studies reviewed three articles each mentioned the region of origin but not the country such as africa latin america or south east asia however somalia was the most common country of origin with six articles focusing on this group this was followed by cambodia myanmar syria bhutan and the democratic republic of the congo additional countries such as eritrea sudan vietnam afghanistan iraq and germany were mentioned in one article either as the sole population of interest or as part of a group there was significant variation in the country of origin in the articles reviewed there was less variation regarding the country of resettlement in 17 of the articles the country of resettlement was the us this was followed by australia and the united kingdom the other countries of resettlement were jordan belgium the netherlands south korea sweden finland and germany only one article did not mention resettlement in a specific country but stated that resettlement was in europe most of the articles focused solely on women including one article that included minor girls and another one article that focused solely on elderly women three articles focused on elderly men and women and 13 articles included both men and women of all ages the four remaining articles were literature reviews in which there was no emphasis on gender the results are organized into subsections based on the major themes of violence and mental health social support and healthcare access violence and mental health limited data currently exist examining refugee womens experiences of sexual assault andor intimate partner violence 20 however most adult refugees are women who consistently demonstrate high levels of trauma 112021 young refugee women are vulnerable to experiences of sa andor ipv during the migration process they thus need reproductive health care during resettlement 2022 one study in california found one in three refugee women reported having experienced a traumatic event prior to migration 17 physical assault 117 captivity 105 sexual assault and 174 weapon assault 20 although limited research exists examining sa and ipv among refugee women the literature shows that refugee women resettled in western countries possess a tenfold risk of developing posttraumatic stress disorder symptoms compared to nonrefugee women 21 refugee women face unique challenges related to exposure to prior conflictrelated trauma experienced before and during the migration process as well as vulnerabilities related to resettlement 2021 hence in an effort to provide culturally safe care it is imperative that providers working with refugee women recognize this vulnerability and seek to prevent the occurrence of retraumatization 21 that may be perpetrated by a husband or partner 22 or even inadvertently by a provider through secondary victimization secondary victimization refers to behaviors and attitudes of social service providers that are victimblaming and insensitive 23 victimization by a provider is similar to victimization by a perpetrator in that both ignore the victims needs and devalue their experiences 23 if the healthcare needs of refugee women who experienced sa andor ipv are to be adequately addressed it is essential that healthcare institutions provide flexible and comprehensive services that are capable of engaging refugee women as participants within their plan of care keygnaert and colleagues 18 conducted a qualitative study with migrants and refugees in holland and belgium in which they found that healthcare mental health services and social services need to be readily available hence services such as rape crisis centers and ipv shelters play vital roles and should be available in the us the violence against women act stipulates payment for sexual assault exams and medical forensic exams for all survivors of sexual assault including refugees 24 these services are provided in collaboration with communitybased advocacy organizations which is considered best practice for survivors of sexual assault 24 however access to forensic exams may be difficult due to lack of trained nurse examiners as well as lack of relevant programs 25 social support social support refers to a tangible social network and the psychological benefits and resources available within the network to help individuals cope and improve their quality of life 26 social support is grouped into three main types emotional informational and instrumental 27 and comes from many avenues family friends coworkers religion and the community refugee women acknowledge the importance of social support but also face barriers to maintaining it 28 refugee women are frequently separated from family and friends dispersed in unknown areas away from their communities and sometimes cannot communicate in the host countrys language strong social support networks particularly those developed shortly following resettlement can improve access to healthcare services reduce isolation increase life satisfaction mediate stress from discrimination and protect against poor physical and mental health outcomes 29 length of time in the us may play a role in social support kingsbury et al 30 examined factors associated with social support networks of pregnant bhutanese refugee women in ohio women who had resettled from another city or state in the us were more likely to report high levels of social support which was mainly provided by family members and spouses than women who had resettled directly from bhutan 30 with approximately 25 of women refugees being of reproductive age 30 social support can be vital in pregnancy outcomes 30 women who have children or give birth shortly after migration face elevated levels of physical and emotional hardship and social support tends to be lower as they often lack the family and community support in raising their children that would be present in their home country 31 social support can also play a major factor in parenting as many women struggle to transition from a more interdependent culture in their country of origin with a large network of family and community support to a more independent culture in the us that emphasizes autonomy and individualism 32 many refugee women want to keep issues within the family and are reluctant to reach out to healthcare facilities or individuals with a different background than themselves 33 moreover many refugees contend with a loss of resources during migration both physical and social experience a renegotiation of their roles in their new communities and cope with stress and institutional racism in the us 19 social support from women of similar backgrounds and support from mothers in the host country often through church groups or nonprofit organizations help women transition to the shift in culture though social support among women from similar backgrounds seems to be cited by women more often than other sources 30 english fluency also moderates the value of social support from the host community meaning refugees who speak or understand english are more likely to engage better with the host country and thus experience enhanced social support compared to those who do not speak or understand english 34 health care migrating to a new country comes with anticipated and unforeseen challenges 35 which include language barriers 36 culturally discordant health beliefs 37 38 39 40 issues with education access 41 limited knowledge of the host culture 42 and difficulties with healthcare access healthcare access challenges include cultural differences regarding understanding of health care 40 health insurance 39 low health literacy communication challenges and in some cases racial discrimination these challenges are more prominent particularly for female refugees as they intersect with other reproductive health needs that may significantly affect access to healthcare services 4043 given the circumstances surrounding their migration to the us many refugee women have limited or no formal education 37404344 moreover their children are less likely to be in school only 24 of high schoolage refugees are enrolled in high school and even fewer continue their education past secondary school 5 the disparity grows when it is disaggregated by sex whereby f or every ten refugee boys in secondary school there are fewer than seven refugee girls 5 which has implications for health given that those with lower education levels have poor health outcomes 45 in addition education influences health literacy and previous studies have found that health literacy mediates the relationship between education health status and health behaviors 4647 the challenges facing refugees in the countries they resettle in are not strictly related to lack of healthcare support as the us and germany for example have established programs that cater to the healthcare needs of refugees at least for a limited period 4849 there are deeper structural issues that impact access to healthcare services by this population including communication and cultural issues communication with healthcare providers communication is a major challenge for refugee women when accessing us healthcare services 39445051 this challenge presents in various forms including limited english proficiency limited health literacy lack of interpretation services and lack of interpersonal relationships 40 in reporting the challenge of lack of interpersonal relationships carroll et al found that refugee women from somalia reported concerns about depersonalized care being rushed through the visit … and demonstrations of impatience or visible frustration due to language barriers on the part of healthcare providers or staff 43 this is an example of culturally unsafe care given the collectivist culture in many african countries 52 the sample of women in the study had expectations of collegial interactions with their providers however their expectations were unmet as a result of the structure of the us healthcare system and other challenges that made women feel disrespected and devalued because their providers did not display the level of interpersonal relationship they expected a lack of culturallyappropriate interpretation services is another dimension of communication challenges as mentioned earlier reproductive health is a salient part of womens lives especially among many refugee women discussing issues of reproductive health with healthcare providers can be particularly challenging for refugee women 37 for instance in another study with somali refugee women 37 female circumcision a cultural reproductive health practice for many somali women was considered to be a challenge when interacting with healthcare providers because many were unaware of this practice female circumcision can be an emotionally charged subject and healthcare providers should avoid imparting judgement stereotyping and stigmatizing women who have undergone this procedure 53 this is where cs can inform healthcare practice critical reflection on personal feelings and bias around this practice needs to take place prior to working with the patient the healthcare provider should be prepared to preserve the patients sense of dignity and provide appropriate health care when the situation arises language barriers versus access to culturally appropriate interpretation services are reported to be another major challenge for refugee women in a qualitative study mirza et al found that interpretation services come with challenges such as finding trained interpreters who can understand the multiple languages that refugees speak 39 these communication challenges are a barrier to refugees accessing healthcare services 39 literacy and language challenges hinder the promotion of health equity for refugees accessing healthcare addressing the challenges of lack of interpreters cultural differences in health care and institutional racism requires changes at the interpersonal point of healthcare access as well as at the organizational and societal levels this may include allowing for additional time for providerpatient interactions in order to make accommodations for relationship building addressing language barriers and unique health education needs health educators also need to be adequately educated and informed about the various healthcare beliefs practices and needs of the refugee populations with whom they interact refugees face barriers when navigating complex systems such as health care and health insurance 54 including access to transportation complexities of health insurance plans and the cost of health care 55 logistical issues such as scheduling hours of services wait times for appointments child care during appointments and transportation are recurrent challenges 55 issues around insurance enrollment or lack of insurance through an employer create additional gaps with healthcare cost and insurance access 55 these are community and organizationlevel issues that lead to avoidable consequences such as missing appointments or lacking insurance reavy et al 56 proposed a new clinic model for addressing the barriers to accessing healthcare among refugees through a case study that utilized an ecological care model named care this model drew upon the theory of cultural safety 56 the nurseled clinical program provided a smooth continuum of care as well as education specific to refugee patients and family wellbeing which was taught by a clinical health advisor in a group setting the model considered power dynamics bridged the gap between providers and refugees built a relationship based on shared perspectives provided by a clinical health advisor who was also of the same background as the refugee and thus provided additional lived experience peer support 56 the clinical health advisor may encounter challenges related to lack of communication with healthcare providers since they are not certified medical interpreters privileged to know patient or visit information 56 however health education programming involving the use of clinical health advisor may bridge the gap in understanding between refugees and providers and thus contribute to positive impact on health outcomes and reduction in disparities 57 mancuso highlighted the importance of considering how health care culture and social setting are interconnected and suggested a strengthsbased bidirectional approach to community outreach and programming focused on eliminating barriers by leveraging refugee community strengths 57 further mancuso stressed the importance of building trust communication and collaboration in order to effectively engage with the healthcare system 57 discussion refugee women are a vulnerable population with unique needs requiring particular attention of which their providers need to be aware 58 as previously noted while sem is not a theory and cannot tell us about the relationship between constructs 16 sem does help us conceptualize the multilevel factors that impact health adhering to the assumption of ecological models that the interaction between the levels is dynamic 1415 what this means is that while we cannot explicate the relationships between variables as it is outside the scope of sem in this article we need to remember that these levels do influence one another and interventions that are multilevel tend to be more effective for that reason 16 our review of the literature shows that factors that perpetuate health inequities among refugee women include individual interpersonal organizational and community factors and hence different levels necessitate different recommendations recommendations according to the adapted sem framework individual and interpersonal levels the individual and interpersonal levels within the adapted sem framework are discussed together because addressing individual factors involves interpersonal interactions for example a refugee woman with minimal formal education is at risk of poor health outcomes due to potentially low health literacy however to improve the level of health education this involves interpersonal communication with a provider migration history age level of education knowledge about services and beliefs about health all shape an individuals susceptibility and resilience to poor health during migration and postsettlement 518203740434454 for example a low level of formal education and a difficult migration history have the potential to lead to poor health status and health behaviors 214647 communication with providers and appropriate screenings and referrals are therefore important for promoting health equity among refugee women at the individual and interpersonal levels while healthcare providers are not expected to offer formal education improved communication through greater time dialogue and clarity of medical questions and instructions may help to bridge gaps in health literacy hence those providing services to refugee women should be privy to and ask about the individuals experiences and preferences when receiving care asking about preferences and how one would like to be treated is a way of conferring some choice to the refugee moreover mental health screening particularly perinatal and ptsd screening is vital for refugee women 59 while mental health screening forms exist this screening is optional 9 providers should incorporate these screenings as part of standard procedure additionally evidence shows that poor social support among refugees contributes to poor wellbeing which suggests a need for screening for social support 59 part of interpersonal communication between providers and refugees should emphasize making women aware of available services a survey of refugee women coping with postpartum depression found many were unaware of services available to them but once aware they generally found the services useful 60 in addition many services were different from what was available in their country of origin thus women may not even know what to look for 60 consistent with other studies positive relationships with providers and social support from family friends and intimate partners increases the likelihood of seeking accepting andor continuing care 60 providing culturally safe care by critically analyzing how social political and historical factors may impact the health of refugee clients based on evidence is critical in order to deliver care that does not demean retraumatize or further marginalize refugee populations by developing a deep understanding and acknowledgement of how multilevel structural factors such as racism and providerclient power differentials impact the lived experiences of refugees both within their healthcare encounters and society at large providers can then engage in critical reflexivity on how their practices and beliefs relative to refugee clients are shaped by the same structural factors organizational level it is crucial that healthcare providers are aware of other organizations serving refugees compiling a list of local organizations serving refugees and the services they provide and providing this list to patients would help streamline connection to services additionally to improve transition in care the use of volunteers to aid with healthcare system navigation is an effective approach 61 community level providers serving refugees can educate faith and community leaders on the psychological stressors faced by refugee women and encourage compassion confidentiality and regular contact this can be beneficial in increasing resources for social support for women as well as in identifying women at risk 62 identifying local organizations and community representatives and engaging them in determining ways to better serve women could be a valuable approach in addition when women present themselves at a healthcare facility providers have the responsibility to offer compassionate culturally humble and collaborative care language also tends to be a major barrier to accessing social support in the host community encouraging involvement in english language courses 34 or increasing availability of interpreters facilitates further social support and helps ease the transition limitations this article did not consider a comprehensive review of discrimination and violence particularly sexual violence faced by refugees racial discrimination is briefly mentioned as it relates to service provision however further elaboration was beyond the scope of this article but is an important consideration for future research to contribute to filling the gap in the literature on the topic we also recognize that each refugee and each group of refugees may have vastly different needs and that this article is a synthesis of the literature as it relates to all refugee women which may be a limitation to identifying the needs of specific groups moreover much of the literature combined immigrants and refugees thus it was in some cases difficult to ascertain evidence specific to refugees additionally this paper lacks specific evidence for older adult refugee women there is limited research on the experiences of older adult refugee women and their unique experiences aging refugees have often resided in the us for years or decades 63 and not much is known about their needs and challenges following their immediate resettlement 63 64 65 66 67 furthermore the studies cited in this article have varying study designs and sample sizes many of which were small which may affect the interpretation and generalizability of our findings conclusions violence lack of social support and limited access to services can negatively impact the health of refugees thus promoting the health of refugee women in order to enhance health equity by preventing and reducing avoidable and unjust outcomes requires a multilevel and multisystem approach social support culturally safe providers and patient navigators can increase refugees comfort knowledge participation and trust in the health system improved communication between organizations can streamline care and reduce barriers to accessing services while greater recognition of the changed roles and resource loss that many refugee women face and working with the community to devise solutions can improve the health of refugee women authors contributions mh wrote the introduction background section socialecological model section and discussion recommendations and conclusion section she also coordinated all authors through the entire process critically reviewed revised and prepared this manuscript for publication ms wrote the social support section discussion section and provided support by editing reviewing and revising the manuscript cta wrote the sections on communication with healthcare providers and worked to integrate cultural safety in the interpretation of findings she also critically reviewed and provided editing support jw also wrote on cultural safety worked to weave cultural safety throughout the manuscript and provided editing support she also critically reviewed and provided editing support oo also wrote on cultural safety worked on integrating this framework through the manuscript and provided editing support she also critically reviewed and provided editing support ad made significant revisions edits and reviews of the manuscript and aided in the preparation of the manuscript ac wrote the section on systems navigation and provided editing support ar wrote the section on sexual assault and intimate partner violence in the lives of refugee women kg also wrote the background and conclusion sections kq critically reviewed revised and aided in the preparation of this manuscript lmv conceptualized this study and aided in critically reviewing revising and preparing this manuscript the author read and approved the final manuscript funding none of the authors received funding of any kind to conduct this work consent for publication not applicable competing interests mh ac oo jw and lmv have nonfinancial competing interests these authors work or have worked directly with refugees and refugee serving organizations author details 1 joseph j zilber school of public health university of wisconsin milwaukee milwaukee usa 2 department of communication studies towson university towson usa 3 college of nursing university of wisconsinmilwaukee milwaukee usa 4 center for advancing population science medical college of wisconsin milwaukee usa 5 master of sustainable peacebuilding college of nursing university of wisconsinmilwaukee milwaukee usa 6 jackson school of international studies western washington university bellingham usa received 8 april 2020 accepted 18 january 2021

the health of refugee women after settlement in a new country can be adversely or positively affected by individual interpersonal community and organizational factors while much of the previous literature highlights these factors individually there is a lack of comprehensive synthesis regarding how the factors interact to influence the health of refugee women we conducted a thematic analysis in our literature review to elucidate how providers can work with refugee women to prevent adverse health outcomes and intervene at multiple levels to improve their health outcomes after resettlement we reviewed peerreviewed literature from 2009 to 2019 from google scholar jstor global health pubmed cinahl sociological abstracts and social service abstracts and also used citation chaining to identify relevant information pertaining to refugee womens health the key terms used for our literature review were health care violence social support and mental health in total we included 52 articles 3 books and 8 other sources we found that refugee women are vulnerable to violence during migration and typically have high rates of posttraumatic stress disorder there were also concerns of secondary victimization by providers after resettlement we also found that social support is an important factor for reducing isolation and improving access to health care as well as improving mental health outcomes however social support was often difficult to maintain and was moderated by factors such as english language fluency health care was influenced by health literacy cultural difference communication concerns and access issues the findings suggest that at the individual and interpersonal levels there is a need to address language barriers improve providerpatient communication and provide appropriate medical and mental health screenings at the organizational level interorganizational communication and awareness are vital at the community level providers can work with community leaders to educate create dialogue and collaboration to help facilitate understanding and bolster community social support improved communication and knowledge about the unique needs and concerns of refugee women through an integrated multisystem approach is necessary to improve their health outcomes

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background opioid dependence frequently manifested as heroin dependence is a chronic illness that when untreated can result in adverse health consequences such as bloodborne viral infections endocarditis and drug overdoses 12 illicit opioid use is also associated with severe psychosocial problems such as homelessness unemployment loss of family bonds and illegal activity 3 survival sex work is very common among street drug users and has been associated with increased drug related harms 4 5 6 7 although data indicate that women as well as men using drugs engage in sex work women who use injection drugs are more likely to be involved in survival sex work compared to men 489 data suggest that women who are injection drug users and engage in sex work present greater vulnerabilities compared to nonsex workers using injection drugs for example they are more likely to have unstable housing 410 higher rates of incarceration 4 10 11 12 and fewer years of education 12 these women are also more likely to report daily injection heroin use 10 higher rates of cocaine use 4 and binge drug use 13 these observations suggest that women who use injection drugs and engage in sex work may be more vulnerable to adverse physical and psychological consequences of injection drug use chronic health conditions and infectious diseases such as human immunodeficiency virus infection 1415 hepatitis c 16 and sexually transmitted infections are highly prevalent among female sex workers using injection drugs this has been supported by studies showing that hiv risk behaviours including sharing injection equipment 4101117 and inconsistent condom use with clients 1017 are common risk behaviours moreover a recent study found that engaging in risky injection practices was more likely among female sex workers with psychological distress 17 indicating an association between psychological health and disease risk psychological health has previously been measured among sex workers and nonsex workers accessing opioid agonist therapy in a sample of injection drug using women accessing mmt 12 it was determined that sex workers had greater psychological symptoms including depression anxiety psychosis and hostility compared to women not involved in sex work oat is widely considered the most effective intervention for opioid dependency 18 oat has been proven effective at reducing illicit drug use and illegal activities hiv infections as well as improving general health and psychosocial adjustment 2 18 19 20 there is evidence showing that involvement in sex work may be negatively associated with oat access and outcomes including reduced access to care 42122 and early withdrawal from a lowthreshold program 23 moreover a recent randomized clinical trial comparing heroin assisted treatment to methadone maintenance treatment found female sex workers had higher illicit drug use and poorer health outcomes after 12 months of treatment relative to those not engaged in sex work 8 the studies described above suggest that among women using injection drugs sex work is a factor that may deter women from being engaged retained and responding to oat however the factors that are associated with engaging in sex work after entering treatment are not well understood the present study aims to determine if health illicit drug use and treatment retention were associated with engaging in sex work after initiating oat in a cohort of longterm opioid injection drug users methods design setting and participants the north american opiate medication initiative was an openlabel phase iii rct comparing supervised injected diacetylmorphine and oral methadone in the treatment of longterm opioid dependence participants profile study design methodology and results of the parent study have been published elsewhere 24 25 26 briefly eligible participants were at least 25 years of age with a minimum of 5 years of opioid dependence current daily injection of opioids at least two prior treatment attempts for opioid dependence and no enrolment in oat within the prior 6 months a total of 251 individuals were randomized to receive oral methadone or injectable opioids oral methadone was dispensed daily and injectable medications were administered up to three times daily under the supervision of nursing staff participants were also offered psychosocial services and primary care on site and all services were delivered in a patientcentred fashion 27 medications were provided for 12 months since injectable medications were not licensed for addiction treatment an additional 3month period was provided to taper and transition those in the injection group to other treatment modalities all participants provided written informed consent and the study was approved by the university of british columbiaprovidence health care and centre de recherche du centre hospitalier de luniversité de montréal research ethics boards measures a research team independent of the clinic services obtained outcome evaluations at baseline and followup using the european addiction severity index the maudsley addiction profile and health related quality of life instrumenteuroquol for the purpose of the present study participants were considered retained at each evaluation if they received addiction treatment on at least 20 of the 30 days in the month prior to the evaluation information related to sex work was obtained from the employmentsupport status questionnaire of the europasi participants responded dichotomously to whether or not they received money from prostitution in the prior 30 days analysis continuous variables were described by means median standard deviations and interquartile range while frequencies and proportions summarized categorical variables a multivariate logistic regression model estimated by generalized estimating equations algorithm for repeated measures was used to determine factors associated with reporting sex work at baseline to evaluate the relationship between sex work and study variables measured during the 12 month treatment period and up to 24 months followup a bivariate logistic regression analysis adjusted by baseline sex trade involvement was used variables that were determined significant at p value ≤ 01 in bivariate analyses were included in the adjusted multivariate logistic regression model estimated by generalized estimating equations algorithm for repeated measures ethnicity age study site randomization arm and treatment retention were added throughout the group variable and final model selections odds ratios and 95 confidence intervals were calculated missing observations were considered as missing in the analysis only four of 154 men reported engaging in sex work therefore analyses were performed for women only of the 97 women entering treatment we obtained outcome measures for 81 women at 24 months results a total of 52 women receiving oral and injectable medications reported being involved in sex work in at least one of the seven research visits thirteen women who were not engaged in sex work at baseline reported doing so at some point during the followup period while 10 of the 52 women were consistently involved in sex work at each of the seven research visits the multivariate analysis of factors associated with baseline sex work indicated that younger women and women with less education were more likely to engage in sex work the bivariate logistic regression analysis adjusted by baseline sex trade indicated that treatment retention and health related quality of life were inversely associated with sex work sex work was more likely among women with poorer scores in social relations greater physical and psychological health symptoms and more days of illicit heroin cocaine and injection drug use in the prior month women considered to have a high or medium number of days of injection drug use in the past 30 days were more likely to report sex work compared to women with low days of injection in addition compared to women who injected the least amount of times per day those with the most frequent daily injection were more likely to report sex work in the prior 30 days there was a suggestion that injectable treatment had a protective effect on engagement in sex work with an adjusted odds ratio of 83 however this was not statistically significant with only about 45 women in each arm of naomi the power to detect an odds ratio of 8 is virtually nonexistent in the multivariate logistic regression gee model women with more days of heroin and cocaine use and greater psychological symptoms in the prior month were more likely to engage in sex work compared to those with less psychological symptoms and days of heroin and cocaine use discussion the aim of this study was to determine factors associated with engaging in sex work among longterm opioid injection drug users receiving oat in the frame of a clinical trial a higher proportion of women compared to men reported engaging in sex work at treatment initiation women who were younger and had fewer years of education were more likely to be engaged in sex work factors which have previously been associated with sex work among women using injection drugs 41012 housing ethnicity and incarcerations have also been documented in previous studies 4 the lack of such associations in the present study reflects the homogeneity of the naomi sample possibly due to study inclusion criteria when examining factors associated with sex work involvement during the study period women with poorer treatment outcomes were more likely to engage in sex work specifically lower treatment retention poorer scores in social relations and health related quality of life more days of illicit drug use injection drug use and more frequent daily injection in the prior 30 days these findings indicate that sex work was more likely among a subgroup of women who did not fully benefit from oat a noteworthy finding considering that oat has shown to reduce many of the harms associated with longterm heroin use 218 moreover in the present study women who were retained successfully in oat were less likely to be involved in sex work and therefore experienced a reduced vulnerability to harms caused by injection drug use while this is not a causal association it indicates that those involved in sex work were more likely to dropout of treatment in the multivariate model psychological symptoms and high illicit heroin and cocaine use in the prior 30 days were associated with sex work similarly previous studies have found that sex workers accessing mmt 12 and syringe exchange programs 10 presented with higher psychological distress compared to women not engaged in sex work in addition a higher use of substances 13 including more frequent daily heroin and cocaine use 410 has also been reported among injection drug using women who also engage in sex work the results of the present study complement prior research in the context of a prospective design that allowed us to capture predictors of sex work involvement over a 24 month study period after engaging these participants in oat women who continued engaging in sex work were more likely to continue using heroin and cocaine independent of oat retention thus many women continued engaging in survival sex work and using illicit heroin despite that oat improves retention and reduces illicit heroin use the complexity of the relationship between oat effectiveness and its impact on sex work engagement requires further study education is regarded as a strong indicator of social and healthrelated inequalities 31 and women with fewer years of education were more likely to engage in sex work at treatment initiation these findings indicate that women with less education experience further vulnerabilities even within a population with very low socioeconomic status therefore those who provide addiction treatment services must consider this special circumstance acknowledging womens financial needs and the stigma attached to sex work so that services and policies do not further exclude these groups the present study focuses on longterm opioid injection drug using women with and without involvement in sex work it is well known that opioiddependent individuals often show poor mental and physical health as well as poor psychosocial functioning especially after longterm use 33233 there is also growing research evidence among women and men accessing oat demonstrating that women enter treatment with worse physical and psychological health 89 as well as higher opioid and stimulant use 343535 some evidence has also suggested that women have poorer oat outcomes compared to men 89 therefore women using injection drugs represent a particularly important group in the provision of effective addiction treatment unexpectedly there was no association between victimization and sex work in the present study previous studies have shown high rates of physical and sexual abuse in sex workers childhood and later victimization by partners 1236 and clients in adulthood 37 moreover in a cohort study of youth using substances childhood sexual abuse was independently associated with sex work 38 one possible explanation for the absence of this expected association may be related to the measure of victimization the addiction severity index has been used to evaluate abuse in several studies 39 measuring victimization with a general question therefore 40 41 42 details regarding the nature of the event which might account for the associations between victimization and sex work are undetermined 4344 limitations of the naomi study have been discussed elsewhere 2425 it should be noted that the analysis were intenttotreat therefore some of the higher intensity drug use occurred in participants who were not receiving the treatments as provided in the study several gender sensitive and sex work specificrelated questions were not part of the study evaluation package that data would have provided a more detailed picture of the situation in addition the trial was not designed to investigate factors associated with sex work and we had a small sample size however it provided an opportunity to obtain valuable information on this topic in the context of women receiving oat in order to better conceptualize the relationship between high intensity drug use and sex work additional data regarding the reasons for sex work involvement during treatment the proportion of earnings used from sex work to support illicit drug use and information regarding the people who depend on an individual involved in sex work should be captured the findings presented suggest that participation in naomi positively affected the pattern of sex work showing a decline from enrolment to 24 months followup at treatment entry all naomi participants had not received any treatment for the six months prior to study enrolment therefore considered untreated despite the available options engagement in treatment was associated with a decline in sex work over time this particular group would have likely remained outside of addiction treatment services and likely only initiated treatment for the opportunity to receive injectable diacetylmorphine certainly approaches that improve treatment engagement for longterm treatment refractory heroin injectors must be supported by current policies conclusion findings of this study suggest that injection drug using women engaged in sex work represent a highly vulnerable group with poorer psychological health and a greater use of heroin and cocaine while receiving oat future research should aim to better understand the circumstances around illicit drug use and sex work among opioiddependent individuals receiving oat as these activities impact treatment outcomes and the addiction recovery process in addition mixed methods studies exploring sex workers perceptions of oat and barriers to treatment engagement may provide valuable information for the development of future interventions and design of tailored services which should aim to simultaneously reduce the harms associated with injection drug use and sex work and interpretation of data in the writing of the report or in the decision to submit the paper for publication the authors wish to acknowledge the dedication of n laliberté c gartry k sayers pa guevremont p schneeberger k lock j chettiar j lawlor p pelletier s maynard mi turgeon g brunelle a chan s macdonald t corneil j geller s jutha s chai m piacsezna s sizto the many remaining staff and members of the dsmb the authors also wish to recognize the many us and canadian scientists who contributed to the early design discussions but ultimately were unable to participate in the trial most importantly the authors wish to acknowledge and thank the naomi trial participants authors contributions mts sb dm made substantial contributions to conception and design of the study mts sb dm eoj and dg made substantial contributions to acquisition of data and analysis and interpretation of data km made substantial contributions to analysis and interpretation of data the first second and last author wrote the first draft of the paper the senior statistician performed the data analyses all authors critically revised the manuscript for important intellectual content the final decision about publishing the paper was made by all the authors competing interests the authors declare that they have no competing interests

background substitution with opioidagonists eg methadone has shown to be an effective treatment for chronic longterm opioid dependency survival sex work very common among injection drug users has been associated with poor opioid agonist treatment oat engagement retention and response therefore this study was undertaken to determine factors associated with engaging in sex work among longterm opioid dependent women receiving oat methods data from a randomized controlled trial the north american opiate medication initiative naomi conducted in vancouver and montreal canada between 20052008 was analyzed the naomi study compared the effectiveness of oral methadone to injectable diacetylmorphine or injectable hydromorphone the last two on a double blind basis over 12 months a research team independent of the clinic services obtained outcome evaluations at baseline and followup 3 6 9 12 18 and 24 months results a total 536 of women reported engaging in sex work in at least one of the research visits at treatment initiation women who were younger and had fewer years of education were more likely to be engaged in sex work the multivariate logistic generalized estimating equation regression analysis determined that psychological symptoms and high illicit heroin and cocaine use correlated with womens involvement in sex work during the study period conclusions after entering oat women using injection drugs and engaging in sex work represent a particularly vulnerable group showing poorer psychological health and a higher use of heroin and cocaine compared to women not engaging in sex work these factors must be taken into consideration in the planning and provision of oat in order to improve treatment outcomes trial registration nct00175357

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introduction adult chil dren pro vide impor tant sup port for older par ents and help facil i tate their social engage ment however trends toward later mar riage more life long singlehood and lower fer til ity in recent decades have led to a grow ing pop u la tion of amer i cans with out chil dren understanding the prev a lence and char ac ter is tics of older amer i cans with out chil dren is essen tial for devel op ing strat e gies to address their health and social care needs yet mea sur ing child less ness is com pli cated by the grow ing com plex ity of fam ily struc ture high lev els of mar i tal dis rup tion have resulted in a tri pling of the num ber of remarried amer i cans between 1960 and 2013 as a result many indi vid u als with out bio log i cal chil dren may have stepchildren whereas some bio log i cal chil dren may become estranged from divorced or repartnered par ents the fre quency of par entchild con tact and the extent of inter gen er a tional sup port also vary sub stan tially and older par ents may out live their chil dren and become elder orphans thus the con cept of par ent hoodchild less ness reflects a con tin uum rather than a sim ple dichot omy prior stud ies have mea sured child less ness using var i ous def ni tions rang ing from bio log i cal infecundity to lack of any quasiparen tal ties and dif fer ing in whether they account for con tactvital sta tus of the child depending on the def ni tion used the size of the child less pop u la tion its char ac ter is tics and its health out comes may dif fer in mean ing ful ways this can have impor tant impli ca tions for pol icy dis cus sions seek ing to address the needs of this pop u la tion this study aims to pro vide new evi dence to encour age crit i cal think ing about the mea sure ment of child less ness to this end we applied three dif fer ent def ni tions of child less ness rang ing from a restric tive bio log i cal def ni tion to a more expan sive social def ni tion to a national sam ple of mid dleaged and older amer i cans to illus trate how dif fer ent def ni tions may affect our under stand ing of the child less pop u la tion we com pared the prev a lence of child less ness cor re lates of child less ness and dis tri bu tions of lone li ness and liv ing arrange ments among the child less pop u la tion using each def ni tion because the social con text and mean ings of child less ness have changed sub stan tially over time and the effects of par ent hood and chil dren can vary at dif fer ent life stages we included indi vid u als span ning mid dle age through late life methods we used data from the health and retirement study a lon gi tu di nal panel sur vey of amer i cans conducted every two years since 1992 to con struct a nation ally rep re sen ta tive sam ple of mid dleaged and older amer i cans we included respon dents aged 55 or older this is the age range for which hrs anal y sis weights are avail able for both com mu nitydwell ing and insti tu tion al ized indi vid u als we ana lyzed data from the 2014 wave of the hrs sur vey includ ing 17183 respon dents born in or before 1959 the nec es sary var i ables were taken from the rand hrs longitudinal file and family data file which con tain cleaned and constructed var i ables com piled from the hrs as well as the rand hrs fat file and hrs tracker file analysis of respon dents lone li ness was lim ited to a ran dom sub sam ple of 6843 respon dents who com pleted the 2014 hrs leavebehind selfadmin is tered ques tion naire all ana ly ses accounted for the com plex sam ple design of hrs to gen er ate nation ally rep re sen ta tive esti ma tes we con sid ered three alter na tive def ni tions of child less ness respon dent never fatheredgave birth to a child respon dent had no chil dren who were liv ing and in con tact and respon dent and spousepart ner had no chil dren or stepchildren who were liv ing and in con tact similarities and dif fer ences across the three def ni tions as well as the var i ables used to con struct each are detailed in table 1 for each def ni tion respon dents who had at least one child meet ing the stated cri te ria for chil dren were coded as being childlessness among middleaged and older amer i cans although not explic itly stated in the hrs ques tion naire a respon dents or spousepart ners own chil dren pre sum ably include adopted chil dren table 1 childlessness among middleaged and older amer i cans a par ent those with unknown sta tus on the rel e vant var i ables or ques tion able link age of child infor ma tion across waves that pre cluded defn i tive deter mi na tion were coded as hav ing unknown child less ness sta tus for each of the three def ni tions we cal cu lated the pro por tion of respon dents who were child less we also com pared the prev a lence of child less ness by key sociodemo graphic char ac ter is tics using chisquare tests and logis tic regres sions adjusting for age to account for econ o mies of scale in con sump tion income and wealth were mea sured using an equiv a lence scale that is by divid ing the sum of respon dents and spouses income or wealth by the square root of two if mar ried or partnered we mea sured lone li ness and liv ing arrange ments for each respon dent because they are par tic u larly rel e vant cor re lates of wellbeing and social sup port for child less older adults loneliness was mea sured using an abbre vi ated 11item revised ucla lone liness scale com pris ing ques tions on feel ings about lacking com pan ion ship being left out iso la tion from oth ers being in tune with oth ers feel ing alone hav ing some one to talk to hav ing some one to turn to hav ing some one who under stands hav ing some one you feel close to feel ing part of a group of friends and hav ing a lot in com mon with friends each item was scored on the basis of the fre quency of the feel ings the over all score is the mean value of the 11 items with neg a tive items reversecoded such that a higher score indi cates greater lone li ness living arrange ment was clas si fed into four mutu ally exclu sive categories liv ing alone liv ing with spouse liv ing with oth ers or liv ing in a nurs ing home to make these liv ing arrange ment categories con sis tent between the child less and par ents we treated coresiding chil dren as oth ers the lone li ness scores of the child less and of par ents were com pared using t tests as well as lin ear regres sions that incre men tally adjusted for respon dents key sociodemographic char ac ter is tics in these regres sions the coef f cient esti mate on the child less indi ca tor reflects the adjusted mean dif fer ence in their lone li ness score the dis tri bu tion of liv ing arrange ments between the child less and par ents was com pared using chisquare tests as well as logis tic regres sions that incre men tally adjusted for respon dents key char ac ter is tics results after apply ing the bio log i cal def ni tion the prev a lence of child less ness was 136 in 2014 about 11 higher than for the func tional def ni tion and 48 higher than for the social def ni tion under all three def ni tions child less ness was low est for indi vid u als aged 7579 in 2014 and was pro gres sively higher among those who were older or youn ger the prev a lence of child less ness dif fered by sociodemographic char ac ter is tics when using the func tional def ni tion the prev a lence was higher among non his panic indi vid u als indi vid u als with higher edu ca tional attain ment childlessness among middleaged and older amer i cans 147 vs less than high school at 79 and indi vid u als who had never mar ried the prev a lence of child less ness dem on strated a ushaped rela tion ship regard ing wealth 146 and 135 in the low est and highest quar tiles of wealth respec tively com pared with 111 and 106 in the mid dlelow and mid dlehigh quar tiles respec tively these sociodemographic dif fer ences remained sig nif cant after adjusting for respon dents age however dif fer ences in the prev a lence of child less ness by gen der were no lon ger sig nif cant after adjusting for age some of these rela tion ships between sociodemographic char ac ter is tics and the prev a lence of child less ness were stron ger when using the more restric tive bio log i cal def ni tion or the more expan sive social def ni tion for instance after adjusting for age women were less likely than men to be child less when using the bio log i cal def i ni tion although there was no sig nif cant gen der dif fer ence when using the func tional def ni tion compared with respon dents who were mar ried or partnered after adjusting for age those who had never mar ried had an or of 2635 for being child less when using the func tional def ni tion but an or of 5458 when using the social def ni tion shifting now to the wellbeing of child less amer i cans child less respon dents had greater lone li ness com pared to those with chil dren when using the func tional and social def ni tions but not when using the bio log i cal def ni tion the dif fer ence in lone li ness between par ents and the child less was mostly explained by respon dents socio eco nomic sta tus when using the social def ni tion but was mostly explained by mar i tal sta tus when using the func tional def ni tion under all three def ni tions the child less were more likely than par ents to live alone rather than with a spouse however the mag ni tude of such dif fer ences was greater when the social def ni tion was used in com par ing the child less with par ents regard ing the like li hood of liv ing alone the adjusted or was 511 when using the func tional def ni tion and 1031 when using the social def ni tion discussion using nation ally rep re sen ta tive data we described the prev a lence and char ac ter is tics of child less mid dleaged and older amer i cans more impor tantly we dem on strated how deci sions about the def ni tion of child less ness can affect our under stand ing of the prev a lence and cor re lates of child less ness and its rela tion ship with lone li ness and liv ing arrange ments depending on the def ni tion used the esti mated per cent age of mid dleaged and older amer i cans with out chil dren ranged from 92 to 136 after apply ing an even broader def ni tion of hav ing no liv ing chil dren a recent study reported that 75 of amer i cans aged 50 or older were child less other research has explored alter na tive def ni tions of par ent hoodchild less ness that con sider the avail abil ity of the circumstances of bio log i cal adopted and foster children and stepchildren as well as of children depending on how child less ness is defned clearly there can be con sid er able dif fer ences in the esti mated size of this pop u la tion childless older adults are thought to have more lim ited social net works and sup port and to be more sus cep ti ble to iso la tion and lone li ness com pared with those who have chil dren however we found greater lone li ness among the child less only when using the func tional or social def ni tion of child less ness simple bio log i cally based def ni tions may not accu rately reflect the avail abil ity of sup port to older par ents as chil dren may die or become estranged conversely defn ing chil dren too broadly may over state the sup port avail able to older par ents as stepchildren often pro vide less assis tance than bio log i cal chil dren and the level of sup port pro vided by stepchildren depends on the qual ity of their rela tion ship with step par ents and recip ro cal help received from step par ents whether the def ni tion of child less ness affects gen der dif fer ences in the asso ci a tion between child less ness and wellbeing as shown in some research also war rants close atten tion in future research the dif fer ent life expe ri ences and fam ily cir cum stances that lead to child less ness can have dis tinct impli ca tions for older adults need for longterm care ser vices and non fam ily sup port for instance older adults with out bio log i cal chil dren may have quite dif fer ent needs for longterm care ser vices depending on whether they have adopted chil dren or stepchildren with whom they are close yet inad e quate scru tiny and clar ity in the def ni tion of child less ness in prior research limit our knowl edge about this pop u la tion hin der ing our abil ity to appro pri ately deploy resources and tai lored inter ven tions to address their needs the design of future data col lec tion and research on child less ness should con sider the vary ing def ni tions and their impli ca tions to enhance crossstudy com par i sons of fnd ings and eval u a tion of gen er al iz abil ity indi vid ual stud ies should clearly defne how child less ness is mea sured explain whether and why some chil dren are excluded and dis cuss the poten tial impact on fnd ings and their inter pre ta tion moreover the plan ning of future sur veys should con sider the per ti nent aspects of par ent hoodchild less ness and ensure that such data ele ments are ade quately cap tured some stan dard i za tion of data col lec tion meth ods and reporting qual ity will likely facil i tate future research in this area we also note how ever that our results are in some cases con sis tent regard less of the def ni tion of child less ness used for instance we found a con sis tently lower prev a lence of child less ness among indi vid u als aged 7579 in 2014 com pared with oth ers who were older or youn ger although our anal y sis was lim ited to a crosssec tional assess ment and can not dis tin guish age and cohort effects this fnd ing is con sis tent with prior research dem on strat ing impor tant gen er a tional dif fer ences in child bear ing among us womenwith the total fer til ity rate peaking among women born in 1935 and steadily decreas ing to 20 per woman among those born in 1960 we also found a con sis tently lower prev a lence of child less ness among his panic indi vid u als a higher prev a lence among indi vid u als with greater edu ca tional attain ment and a ushaped rela tion ship between an indi vid uals wealth and their like li hood of child less ness these fea tures of the sociodemographic com po si tion of the child less can inform tai lored health and social pol i cies despite these unique con tri bu tions our study lacked infor ma tion on respon dents rea son for child less ness prior research has shown that dif fer ent paths to child less ness are asso ci ated with dif fer ent pat terns of fnan cial and non f nan cial sup port that a per son receives or pro vi des likewise older adults who choose not to have chil dren have greater psy cho log i cal well being and feel ings of auton omy and envi ron men tal mas tery whereas invol un tary child less ness is asso ci ated with worse psy cho log i cal wellbeing research that fur ther incor po rates such gran u lar ity into the def ni tion of child less ness will pro vide addi tional insights moreover we focused on mea sur ing child less ness we did not fully assess other rel e vant con cepts such as estrange ment although our func tional and social def ni tions of child less ness excluded chil dren not in con tact we also rec og nize that our focus on a sin gle wave of the hrs data pre cluded us from dif fer en ti at ing age cohort and period effects additional research using lon gi tu di nal data to exam ine age cohort and period dif fer ences in the prev a lence of child less ness and whether these rela tion ships vary by the def ni tion of child less ness will be an impor tant area for future inves ti ga tion this study pro vided much needed data on the prev a lence and char ac ter is tics of child less mid dleaged and older amer i cans the fnd ings dem on strated that our under stand ing of the prev a lence and cor re lates of child less ness as well as the wellbeing of the child less dif fered depending on how child less ness was defned clearer con cep tu al i za tion and more pre cise mea sure ment of the par ent hoodchild less ness sta tus con tin uum are needed when design ing future research and sur vey stud ies ■

measuring child less ness is com pli cated by the increas ing com plex ity of fam ily struc ture using data from the 2014 health and retirement study in this research note we com pared three def ni tions of child less ness 1 respon dent never fatheredgave birth to a child 2 respon dent had no chil dren who were liv ing and in con tact and 3 respon dent and spousepart ner had no chil dren or stepchildren who were liv ing and in con tact results showed that the prev a lence of child less ness among amer i cans aged 55 or older ranged from 92 to 136 depending on which def ni tion was used the asso ci a tion between select indi vid ual char ac ter is tics gen der and mar i tal sta tus and the like li hood of child less ness as well as the asso ci a tion between child less ness and lone li ness and liv ing arrange ments also var ied depending on how child less ness was defned therefore how we defne child less ness can affect our under stand ing of its prev a lence cor re lates and rela tion ships with wellbeing future research on child less ness should care fully con sider the choice of def ni tion and its impli ca tions for research and pol icy dis cus sions

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loneliness is defined as a distressing emotional reaction in response to perceived inadequate social relations loneliness represents a cognitive discrepancy between desired and available social relations it should be distinguished from aloneness which reflects an objective situation characterized by limited social contacts and social isolation a metaanalysis conducted to determine the prevalence of loneliness has concluded that loneliness is particularly translational significance anxiety about aging partially explains differences in loneliness in two different settings designed to reduce loneliness interventions to reduce anxiety about aging might result in reduced levels of loneliness among older adults high at young and old age in a large survey conducted in 25 european countries the prevalence of loneliness ranged between 34 among people over the age of 60 in ukraine and 3 among those over 60 living in denmark in the united kingdom the prevalence of severe loneliness among older adults stood at 7 whereas in the united states a little over onethird of the sample of people over the age of 45 were categorized as lonely these prevalence rates clearly indicate that loneliness is a very prevalent condition in old age in a variety of countries they also stress national variability in loneliness levels older adults are at great risk for both objective aloneness and subjective loneliness for several reasons first research has shown that as people age and become increasingly disabled their social environment becomes confined to their home environment and its nearby surroundings increased morbidity and disability inhibit people from interacting with their social environment indeed increased disability and physical impairment have been shown to affect ones sense of loneliness as well as ones partners sense of loneliness similarly impaired sensory functioning and in particular hearing and vision loss may put older adults at a risk for social isolation and likely result in reduced social contacts changes in older adults social environment as a result of gentrification processes for instance result in reduced opportunities for maintaining old ties increased mortality in ones social network is yet another reason for reduced social interactions in old age with age older adults are more likely to lose their spouse and this might contribute to emotional loneliness and to the perceived absence of intimate contacts retirement too might result in social loneliness this is because retirement disengages older adults from their peers and colleagues resulting in an unfulfilled need for social encounters the negative implications of loneliness are welldocumented and substantial in fact the united kingdom has recently established a new minister to combat loneliness this demonstrates the public significance that loneliness has gained past research has shown how loneliness invades the nights and impairs peoples sleep quality loneliness also affects ones health physical functioning and mental health there is a substantial body of research to demonstrate the risk posed by loneliness to a variety of cardiovascular functions loneliness also poses a substantial risk for depression although still controversial there is research to show that loneliness poses a risk for poorer overall cognitive performance faster cognitive decline and poorer executive functioning moreover a 4year longitudinal study which followed 823 people free of dementia at baseline has shown that lonely people were more likely to develop alzheimers disease even after controlling for objective indicators of social isolation finally loneliness is a significant risk for mortality with past research showing that even those individuals who reported loneliness only occasionally were at risk for death at the 4year followup this strong and conclusive body of research has led researchers to argue that loneliness has an adaptive function as it motivates people to form and maintain social interactions in order to ease the uncomfortable sense of distress brought by it formal settings to potentially alleviate loneliness and increase social participation among older adults both adult day care centers and continuing care retirement communities represent an attempt to allow older adults to age in place for adcc participants aging in place represents living in the community and the adcc aims to alleviate caregiver burden and decrease social isolation among participants for ccrc residents despite an initial relocation required in order to join the ccrc the expectation is that the ccrc would be the last stop and that older adults will age in place thanks to the stepped levels of care the ccrc system provides adccs are open 5 or 6 days per week and provide services for 67 hr per day adccs provide recreational and social activities transportation and nutritional meals adccs also provide physiotherapy occupational therapy nursing care and dietary supervision additional services such as showering shaving or pedicure can be purchased at extra fees similar to adccs ccrcs provide social services such as an opportunity to participate in various classes of arts and crafts sports and recreation additional services such as meals laundry and health also are available upon request and at additional cost many older adults first move to a ccrc following the death of a spouse and the wish to find a social company and support although the transition to the ccrc might be fueled by a social need past research has shown that older adults stronger connections are with people in the outside community and with those they have known for a long period of time even prior to entering the ccrc others have shown that even though family members were the main source of intimate relationship ccrc residents relied on other residents for regular social activities the funding source of adccs and ccrcs is different and this potentially results in individuals of somewhat different socioeconomic backgrounds in each of the settings in israel adccs are covered through funds provided by the long term care insurance law to individuals who suffer from functional impairment and wish to stay at their homes although the law relies on means testing it is quite lenient in an attempt to support a large portion of the population of older adults older israelis who suffer from functional impairment can use the support of the ltcil to purchase home care services adcc services or hygiene services past research has shown that those who suffer from the greatest levels of impairment opt for round the clock home care hence those older adults who require moderate assistance and are still capable of living at home without the assistance of a carer end up attending an adcc ccrcs on the other hand represent a private alternative available only to affluent older adults who purchase the services privately with no governmental assistance provided common to both adccs and ccrcs is the reliance on formal services to alleviate aloneness and sense of loneliness among older adults by providing older adults with a variety of opportunities for social interactions both are geographically confined and segregated by age so that only people over a certain age are eligible to participate functional ability is a common criterion in both settings however whereas adccs are specifically designed to support individuals who have functional impairments ccrcs admit only functionally independent older adults research conducted in the united states has shown that adccs improve the quality of life of older people yet a different study conducted in israel has found no differences in the levels of loneliness between adccs users and nonusers a potential explanation for the limited effectiveness of adccs in addressing loneliness among participants can be found in a qualitative and observational study which has stressed the presence of cliques and territorial battles among adccs users finally it is important to note that the two settings cater to a very small minority of the population of older adults in the country currently the ltci supports almost 17 of the population of older adults in the country of these 74 participate in adccs through the support of the ltci as the majority prefer to receive home care services similarly although the number of ccrcs has been increasing only 3 of older israelis rely on institutional care specifically there are 21315 ccrc residential units in israel of these about 11950 are privately owned units this is compared with other longterm care facilities which amount to a total of 30200 beds given the fact that these two settings offer older adults an opportunity to age in place and the active attempts of both settings to provide older adults with social stimulation and to alleviate levels of loneliness it is informative to compare how the two settings function in that regard nonetheless while comparing these two types of settings it is important to keep in mind the multiple differences between the settings and the people who use them loneliness and anxiety about aging ageism is defined by the world health organization as prejudice stereotypes and discrimination towards age and aging it can be positive or negative and it can be directed towards individuals of any age group ageism can be directed towards oneself or towards others in this study the focus is on one aspect of ageism called anxiety about aging it is manifested in negative emotions towards ones own aging process nelson has attributed ageism to fear of our own future selves this fear is captured in the construct anxiety about aging anxiety about aging is not prevalent only among young people in response to older adults but also among old people in response to other old people or in response to their own aging process a possible link between anxiety about aging and loneliness can be found in the stereotype embodiment theory according to this theory older people are constantly bombarded with messages that the world belongs to the young and that they should look and behave young these messages are internalized at a very young age older adults attempt to disassociate themselves from frailty and decline brought by old age by engaging in active aging or successful aging practices and by making a distinction between healthy and functioning older adults and more fragile older adults in support of this argument past research has shown that older adults have reported a great deal of concern about associating with other older adults who display visible signs of aging for instance ccrc residents have explicitly expressed a great resentment and concern about the need to interact with old people who visibly present as old and frail moreover as their physical and functional abilities decline and residents transition to the assisted living facility their contacts with people in the independent wing of the ccrc tend to decrease this disconnect between older people of different levels of functional ability can be partially attributed to the great fears associated with the aging process as it is the independent older adults who choose to disconnect the relationships with those older adults who become functionally dependent in order not to be reminded of their future prospects the present study although adccs and ccrcs represent different living arrangements and thus attract different users as outlined before they do share similar aims with regard to the facilitation of social contact and aging in place therefore the present study examines differences in the levels of loneliness and anxiety about aging in the two settings compared with older adults in adccs those in ccrcs may report lower levels of loneliness this is because ccrc residents enjoy more favorable conditions including a higher socioeconomic status and limited functional impairment all of which are protective factors against loneliness moreover the fact that ccrcs provide a comprehensive living environment could also serve as a beneficial factor compared with adccs that offer services for more limited periods of the day nevertheless it also is possible that adccs offer a preferred alternative to alleviate loneliness because they allow older adults to remain in their original community with no need to relocate another research question concerns anxiety about aging in the two settings anxiety about aging may be higher among adcc participants compared with ccrc residents because adcc participants already show many visible signs of aging whereas ccrc residents are still celebrating the successful aging model commonly held by third agers alternatively it is possible that the mere fact that ccrcs hide visible signs of aging actually increases older residents anxiety about it finally i examine whether anxiety about aging mediates the relationship between the type of formal setting and levels of loneliness possibly differences in anxiety about aging in the two settings account for differences in loneliness between the settings method the present study was funded by the israel science foundation to examine social networks in adccs and ccrcs as such four adccs and four ccrcs were selected to represent settings of different sizes and geographic locations this selection was partially based on prior qualitative research because the overall goal of the original study was to assess social networks all participants and residents in the respective settings were invited to participate in the study nonresponse rate in the settings ranged between 27 and 41 there were significant differences between adcc participants and ccrc residents with regard to gender marital status and education compared with adcc participants ccrc residents were more likely to be women less likely to be married and had more years of education there were no differences in terms of activities of daily living satisfaction with services or age between the two settings in addition compared with adcc participants ccrc residents were less anxious about their aging experience and reported lower levels of loneliness see table 1 for details measures data were collected through facetoface interviews conducted by trained research assistants interviews were conducted in english or in hebrew each interview lasted about one and a half hours all interviews were uploaded directly to the computerassisted system dependent variable loneliness a shortened version of one of the most widely used scales of loneliness the reviseducla loneliness scale was administered the measure includes three questions respondents were asked to rate on a threepoint scale how often they felt as if they lacked companionship were left out or were isolated from others a mean score was calculated with a higher overall score representing higher loneliness mediator anxiety about aging this is a sixitem questionnaire based on the kafer aging anxiety scale items are scored on a fivepoint scale ranging from strongly disagree to strongly agree the six items were selected from the original scale because they were determined as representing a single factor in past research example questions include i always worried about the day i would look in the mirror and see gray hairs the older i become the more anxious i am about the future a mean score was calculated with a higher score representing greater anxiety controls demographic information age gender education and marital status were gathered based on selfreport satisfaction with services this measure was adapted based on a review of the literature on satisfaction measures that identified several core domains of satisfaction the revised measure was used in prior research participants rated their agreement with nine questions higher scores represent higher satisfaction cronbach alpha for this study is α 078 across the eight sites activities of daily living six items were selected to represent activities of daily living a higher score indicates greater impairment range is between 0 and 6 cronbach alpha for this study is α 082 analysis descriptive statistics were calculated to characterize the sample differences between adccs and ccrcs were explored using ttest analyses for continuous variables and chisquare analyses for categorical variables bivariate relations were examined among study variables next a mediation analysis was conducted i started by regressing the mediator anxiety about aging on the independent variable type of formal setting controlling for age gender education marital status satisfaction with services and activities of daily living finally i regressed loneliness on the independent variable type of formal setting with anxiety about aging as a mediator controlling for age gender education marital status satisfaction with services and activities of daily living mediation was examined using bootstrapping with n 5000 bootstrap resamples in order to test whether anxiety about aging mediated the relationship between type of formal setting and loneliness controlling for age gender education marital status satisfaction with services and activities of daily living bootstrapping draws 5000 random samples to estimate indirect effects in each sample this provides an approximation of the sampling distribution of the indirect effect which is used to obtain a 95 confidence interval around the indirect effect when the 95 ci does not contain zero the effect is considered significant all analyses were conducted in spss results table 2 outlines the correlations between variables older age was correlated with lower levels of education and lower anxiety about aging men were more likely to be married and women reported higher levels of anxiety about aging higher levels of education were negatively correlated with anxiety about aging and loneliness greater satisfaction with the services provided was associated with lower levels of loneliness greater impairment in activities of daily living was associated with higher anxiety about aging and higher levels of loneliness anxiety about aging and loneliness were positively correlated table 3 provides information regarding the mediation analysis being in a ccrc older age being a man and having fewer impairments in activities of daily living were all associated with lower levels of anxiety about aging as for loneliness being in a ccrc being married enjoying a stronger satisfaction with the services having fewer impairments in activities of daily living and a lower sense of anxiety about aging were associated with lower levels of loneliness the mediating analysis revealed that the direct effect of type of formal setting on loneliness remained significant even when anxiety about aging was entered into the model however anxiety about aging had a significant indirect effect suggesting partial mediation of the relationship between type of setting and loneliness discussion research has shown that the prevalence of loneliness is particularly high among older adults and that it has substantial negative consequences loneliness is known to affect the health wellbeing and cognitive functioning of older adults moreover it has even been shown to reduce the number of years older adults can expect to live hence it is important to assess loneliness in various longterm care settings that are specifically designed to address the issue among older adults two such settings are the adcc which provides social services to older adults who reside in the community and the ccrc which provides services to older adults who opt for a residential alternative in order to age in place although the two settings provide different types of services to consumers who differ in terms of their functional status and financial ability the fact that both settings aim to address loneliness in an agesegregated community among other things provides a rationale for further comparison of the two settings with regard to their ability to alleviate loneliness in older adults the present study shows that older adults report higher levels of loneliness in adccs compared with ccrcs this trend continues even after controlling for a variety of sociodemographic variables that potentially distinguish between people who use these two different settings hence even though ccrc residents were less likely to be married and were significantly older they still reported lower levels of loneliness although it is not possible to determine causality from this crosssectional design it is possible that ccrcs provide a better social outlet for older adults than adccs anxiety about ones own aging was higher in adccs than in ccrcs anxiety about aging also was a significant predictor of loneliness and partially accounted for the relationship between type of formal setting and loneliness in agesegregated institutions such as adccs and ccrcs age is a salient feature many times older 10 17 note ccrc continuing care retirement community adults are hesitant about joining such institutions because they are stigmatized in order to overcome the stigma attached to old age older adults differentiate between those older adults who function independently and older adults who require assistance in daily functioning the third age which represents the active and successful aging model celebrates old age as a continuation of middle age this celebration of old age is particularly pronounced in ccrcs which market services to the population of independent older adults and attempt to hide visible signs of decline and disability from the public sight adccs on the other hand represent a completely different model as they specifically target older adults who suffer from disability possibly these two different models of care result in a different approach to aging so that adccs participants are more anxious about aging compared with ccrc residents it is possible that those older adults who are more anxious about their own aging process also tend to distance themselves from other older adults in their environment and this in return results in greater levels of loneliness in interpreting these findings it is important to note the studys limitations this is a nonrepresentative sample and the allocation into adccs versus ccrcs was nonrandom the two types of settings are inherently different in many ways therefore differences between the settings could be attributed to several different mechanisms which were not necessarily accounted for in this study hence we cannot assume inferences about cause and effect the crosssectional nature of the design further alludes to this limitation in addition the study did not account for variability within the different settings as the relatively small number of overall settings did not allow for multilevel analysis finally the anxiety about aging scale contains items that capture death anxiety more so than anxiety about aging nevertheless this study provides important insights for several reasons this study alludes to the potential role that anxiety about aging plays in older adults distressing experience of loneliness research has shown that intergenerational contact and knowledge about aging could potentially result in reduced levels of anxiety about aging these could eventually serve as effective mechanisms not only to ease peoples anxiety about aging but also to alleviate older adults sense of loneliness implications for policy the present findings are important for policy planning although both types of formal settings are currently used by a very small portion of older adults the israeli government as well as other governments around the world actively support the participation of older adults in adccs and view these services as a means to keep older adults in the community for as long as possible this is because adccs offer an economic alternative nevertheless this study similar to past research shows that adccs may not be as effective in alleviating loneliness among older adults hence as suggested by a recent review of the effectiveness of adccs there is a need to further develop and test interventions that target the specific needs of adcc participants it is important to note however that only a randomized controlled trial with several data points and a followup period can provide information about the actual efficacy of adccs to alleviate loneliness as both the present study and iecovich biderman relied on a crosssectional observational design current knowledge should be reviewed with caution the findings present a substantial dilemma for policy makers because ccrcs represent a luxurious alternative which encourages a successful aging model unattainable by most older adults adccs in contrast represent a more economic alternative affordable to older adults and supported by the government nevertheless its effectiveness with regard to loneliness as documented in this study as well as with regard to other wellbeing indicator remains questionable current efforts by the israeli government to move towards nonage segregated services in adccs might alleviate some of the anxiety towards aging such an approach could potentially facilitate more social interactions and reduce loneliness among participants conflict of interest none declared

the present study compares how 2 settings adult day care centers adccs and continuing care retirement communities ccrcs fare with regard to loneliness and anxiety about aging loneliness is a highly prevalent and distressing subjective experience of inadequate social relations which has negative effects on health and wellbeing anxiety about aging is defined as worries brought up by imagining the negative consequences and losses associated with old age the study also examines whether anxiety about aging accounts for differences in loneliness between the 2 settings this study took place in israel where adccs are funded by the national insurance institute of israel and ccrcs tend to be funded by private income and wealth despite notable differences between the settings a common goal of both is to reduce loneliness among older adults a crosssectional design of 4 adccs and 4 ccrcs n 456 results compared with ccrc residents older adults in adccs reported higher levels of loneliness mean sd 146 060 mean sd 178 080 respectively t df 510 448 p 001 and higher levels of anxiety about aging mean sd 296 088 mean sd 327 099 respectively t df 342 440 p 001 anxiety about aging partially accounted for the differences between the 2 settings in levels of loneliness b 003 95 confidence interval ci 0003700651 discussion and implications although it is not possible to determine causality from this crosssectional design it is possible that ccrcs provide a better social outlet for older adults than adccs

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introduction the study of poverty in society has generated numerous theories on its causes and impacts poverty is a condition in which the resources particularly material resources of an individual or group are insufficient to meet their basic needs the world bank expands this definition of poverty as a genuine deprivation in wellbeing that encompasses multiple dimensions these dimensions include low income inability to access essential goods and services required for a dignified life poor health and education levels limited access to clean water and sanitation as well as inadequate capacity and opportunities in the literature of economic theories it appears that the focus has been primarily on how to achieve prosperity through the process of capital accumulation when economics emerged and developed in the late 18th century advanced industrialized countries were entering a takeoff phase according to ww rostow the takeoff period for england occurred around 17831802 other advanced countries in western europe such as france belgium germany sweden and the united states experienced their takeoff phase around 18301900 this indicates that economic theories based on laissezfaire principles by adam smith paved the way for economic growth based on the experiences of these advanced nations as a result economic theories generally revolved around efficiency profit maximization capital accumulation and market expansion however following the great depression of 19291933 economic studies began to address issues such as business cycles growth depression and inflation still referring to the experiences of developed countries while issues of crisis and unemployment were discussed they were largely within the framework of economic growth so when did economic theories start examining the issue of poverty in society a writer from the united states in 1979 wrote a book titled progress and poverty stating that where there is excessive wealth there will also be poverty he argued that harmony does not always exist in society contradicting the postulate of harmony in classical economic thought the classical school of thought claims that there is harmony between individual interests and social welfare if each individual driven by the spirit of competition to meet their own interests ultimately achieves the fulfillment of the overall interests of society based on this postulate which theories were subsequently built upon western capitalism then studies on underdevelopment and poverty in developing countries have been conducted not only by conventional western economic schools both liberal and conventional but also by marxist scholars the case of latin america which is heavily dominated by capitalist economies has given rise to theories about the development of underdevelopment this theory rejects the notion that the causes of poverty lie within the society itself such as lack of capital low education population density malnutrition and so on these factors are merely attributes of poverty instead poverty is rooted in a history of exploitation particularly by foreign or international capitalist economic powers that engage in penetration domination and the draining of profits from peripheral regions to metropolises this theory is essentially an extension of marxs theory of the processes of accumulation concentration and impoverishment at a global level in various disciplines it has been proposed that the determinants of poverty are quite diverse from an economic perspective factors such as the lack or inadequacy of incentive systems to realize individual capabilities economic underdevelopment human capital formation structural elements within a country contradictions within capitalism cultural elements within society and geographical location are mentioned in the sociological view poverty is related to social stratification housing segregation persistent racism support in the form of social capital the impact of social policies and the influence of values and behaviors in the field of psychology poverty is attributed to language development and the accumulation of environmental deficits that lead to poor academic achievement intelligence levels morality and the naturalization of perspectives the consequences of poverty can then manifest in mental disorders such as depression alcoholism personality disorders antisocial behavior and schizophrenia research conducted by gans found that the causes of poverty are related to deficiencies within the individual individual factors trigger the emergence of poverty including individual attitudes human capital and participation in welfare supporting this notion bradshaw blames the poor for creating their own problems arguing that with hard work and better choices the poor can avoid and solve their problems in another study bradshaw discovered that cultural belief systems actually support the subculture of poverty poverty is created or caused by the transmission of a set of beliefs from generation to generation socially generated values and skills held individually individuals should be blamed because they are victims of their own subculture or dysfunctional culture thus the basis of this theory is the culture of poverty the concept of the culture of poverty and social isolation or exclusion provide a framework for explaining how poverty is created and perpetuated in certain environments or among certain groups cultural and environmental factors are related to the influence of the living environment of a community which tends to shape poverty or success this theory was developed by lewis based on the assumption that both the poor and the wealthy have different patterns of values beliefs and behavioral norms the third perspective on the determinants of poverty is the structural factors known as the theory of economic political and social distortions or discrimination according to structuralists poverty is caused by larger economic and social structures the basis of this theory links the sources of poverty to economic political and social systems that limit peoples opportunities and resources to achieve income and wellbeing supporting this view samati et al argue that larger economic and social structures are the causes of poverty the capitalist system creates conditions that promote poverty regardless of individual efforts this theory explicitly explains that in a marketbased competitive economic system unequal initial talents capabilities and resources that determine individual productivity lead to poverty these three determinants of poverty as explained in the above theories will be used to examine the typology of poverty and attitudes towards alternative livelihoods for coastal communities and small islands in south sulawesi empirical reality today shows that poverty remains a major issue that captures global attention several limitations faced by many countries in addressing poverty have perpetuated however the reality today still shows that these various poverty alleviation programs have not fully addressed the root causes of poverty in theoretical studies poverty is rooted in according to davis and sanchezmartinez poverty is a state in which an individual or a group of people particularly in terms of material resources lacks the means to meet their minimum needs the world bank as cited by davis and sanchezmartinez expands on this definition by stating that poverty is defined as a real deprivation of wellbeing consisting of multiple dimensions these dimensions include low income the inability to access basic goods and services necessary for dignified survival poor health and education inadequate access to clean water and sanitation as well as insufficient capacity and opportunities there are several theories of poverty that attempt to identify underlying determinants or causes of poverty these theories as proposed by shaffer relate to the lack or inadequacy of incentive systems to realize individual capabilities economic underdevelopment human capital formation structural elements within a country contradictions within capitalism cultural elements within society and geographical location blank also suggests that theories of poverty can be classified into perspectives of economic theory sociology theory psychology theory anthropology theory and political theory from an economic perspective poverty is caused by economic underdevelopment lack of human capital development dysfunctional capitalist markets social and political power dynamics individual characteristics and behavioral choices and welfare dependence or the socalled poverty trap poverty is attributed to economic underdevelopment lack of human capital development dysfunctional capitalist markets social and political power dynamics individual characteristics and behavioral choices and welfare dependence or the poverty trap from a sociological standpoint poverty is caused by social stratification housing segregation and persistent racism support in the form of social capital the impact of social policies and the influence of values and behaviors turner and amanda assert that from a psychological theory perspective poverty is caused by language development and the accumulation of environmental deficits leading to poor academic achievement intelligencebased psychological theories manifestations of moral deficiency and the naturalization perspective the authors further indicate that the prevalence and occurrence of mental disorders as well as globalization refer to psychological theories on the impact of individual deficiency theory theory asserts that individuals are responsible for their own poverty situation gans as cited by sameti et al believes that individual factors causing or triggering poverty include individual attitudes human capital and welfare participation bradshaw blames the poor for creating their own problems arguing that with hard work and better choices the poor can avoid and solve their problems he further explains that poverty is caused by a lack of genetic qualities such as intelligence that cannot be easily reversed this theory is rooted in american values and the belief in the freemarket system which is considered to provide opportunities for everyone rank as cited by sameti et al emphasizes that the belief in individualism strongly emphasizes individual hard work and responsibility for acquiring basic needs including food housing and healthcare services furthermore theories based on american values and beliefs emphasize that talent virtue and hard work can lead to success and individual poverty is seen as a personal failure due to a lack of motivation culture belief system theory focuses on the belief that poverty is created or caused by the transmission of a set of beliefs values and socially generated skills from generation to generation but held individually bradshaw further asserts that individuals should be blamed because they are victims of their own dysfunctional subculture or culture it is worth noting that this theory is rooted in the concept of the culture of poverty the concept of the culture of poverty and social isolation or exclusion provides a framework for explaining how poverty is created and perpetuated in certain environments or among certain groups cultural and environmental factors are related to the influence of the residential environment that tends to shape poverty or success the theory of the culture of poverty was developed by lewis and is built on the assumption that both the poor and the wealthy have different patterns of values beliefs and behavioral norms this theory argues that the poor become poor because they learn certain psychological behaviors associated with poverty lewis argues that the poor do not learn to study hard plan for the future protect themselves sexually or spend money wisely according to lewis as cited by sameti et al poverty is passed down from generation to generation because children are socialized with values and goals associated with poverty according to economic political and social distortion or discrimination theory for structural theorists poverty is caused by larger socioeconomic structures those who believe in this theory associate the sources of poverty with economic political and social systems that limit peoples opportunities and resources to attain income and wellbeing the same viewpoint is expressed by sameti et al who believe that larger economic and social structures are the causes of poverty they argue that capitalism creates conditions that promote poverty and regardless of individual efforts the structure of some economies such as the united states economy ensures that millions of people become poor in other words more literature indicates that the economic system is structured in such a way that the poor are left behind regardless of their competence the theory also asserts that in a competitive marketbased economic system unequal initial talents skills and resources that determine individual productivity lead to poverty according to davis and moore as cited by sameti et al certain positions in society require specific and sometimes unique talents skills and knowledge they further argue that the conversion of ones talent into such specialized skills and knowledge requires a figart and power and blau and kahn have identified specific features in the labor market that result in deviations from the general laws of wage determination one important consideration is the influence of gender and race on wages hurst documents individual income variations and claims that these differences are due to social factors such as gender and race alkire supports this view when she notes that differences in human capital partly account for income disparities however differential incomes are caused by several social factors including gender and race there is a relationship between labor wages and gender or race and this is socially constructed social constructionists like fischer argue that inequality is the result of deliberate construction created and maintained by social institutions and policies additionally certain demographic characteristics including race gender work disability family size and structure place of residence and age are important factors that can increase or decrease the risk of poverty generally poverty rates are higher in households headed by single parents women minority groups households with a large number of children and elderly individuals with specific reference to rural poverty richardson and london argue that the relationship between poverty and structural inequality is not coincidental or incidental but rather structural and causal to address this issue they suggest that the first step is to break down these barriers followed by building rural economies however abdulai and shamshiry have explained that combating structural poverty only seeks to strengthen the ability of the poor to meet their livelihoods but does not transform society into passive and permanent beneficiaries of aid programs they believe that the theory of structural poverty is rooted in marxist doctrine where the argument is made that the existence of a lowincome class is a creation of the capitalist economic system or bourgeoisie as a strategy of dominance when assessing this perspective from an islamic standpoint it should be clarified that private ownership of property is allowed in islam however such property must be acquired through legitimate means this necessitates significant government intervention to provide an equal playing field for wealth acquisition and the fair and justified redistribution of wealth the geographic gap theory states that poverty is caused by geographic disparities the attempt to theorize poverty along geographic lines has led to the emergence of the geography of poverty according to bradshaw the causes of this poverty represent rural poverty ghetto poverty urban disinvestment southern poverty third world poverty and others that are separate from other theories this theory draws attention to the fact that people institutions and cultures in certain areas lack the objective resources needed to generate wellbeing and income and they lack the power to claim redistribution according to abdulai and shamshiry the use of geographic disparities in poverty analysis assumes the concentration of poverty in certain regions communities and localities within a country and between regions worldwide several explanations are given regarding the factors causing poverty including disinvestment proximity to natural resources density diffusion of innovation and other factors it has long been a conventional belief that advantaged areas will grow more than disadvantaged areas even in periods of overall economic growth the suggested solution to addressing poverty associated with geographic differences is to primarily address the key factors triggering decline in disadvantaged areas abdulai and shamshiry argue that the proximity of poverty conditions creates widespread poverty the attraction of businesses and companies away from one location to another assumes the possibility of impoverishing the other location for example low housing prices in such poor locations can attract more poor people leading to disinvestment in housing by building owners bradshaw affirms that the fact that poverty is more intense in certain places than others is wellestablished and there are many explanations in the development literature as to why some areas lack the economic resources to compete some reasons he provides for poverty disparities include disinvestment proximity to natural resources density and diffusion of innovation according to bradshaw there are three perspectives within this theory one theoretical perspective on the spatial concentration of poverty stems from the theory of economic agglomeration the second from central place theory and the last one involves selective outmigration the theory of economic agglomeration explains how proximity or concentration of similar companies attracts supporting services and markets which in turn attract more companies conversely where poverty and impoverished conditions exist it leads to more poverty central place theory asserts that advantaged areas tend to grow faster than disadvantaged areas even in periods of overall economic growth and there will be multiplier effects but not equalization according to classical economics the perspective of selective outmigration according to wilson cited in bradshaw argues that people from ghetto areas with the highest levels of education the greatest skills the broadest worldviews and the widest opportunities are those who migrate out from urban centers to other places additionally he argues that those who depart are also the best role models in the community and often become civil leaders rural poverty according to bradshaw is similar to selective outmigration the cumulative and cyclical interdependence theory also known as the theory of poverty cycles as described by abdulai and shamshiry explains a type of poverty that occurs when individuals or households suddenly cannot meet their needs due to unforeseen circumstances such as natural disasters the cycle explanation highlights the clear interdependence between individuals situations and community resources in an unstable economy for instance it creates individuals who lack the resources to participate in the economy making economic survival increasingly difficult for the community as people pay fewer taxes bradshaw further explains that inadequate employment leads to inadequate income resulting in insufficient expenditure consumption and savings this assumption implies that individuals are unable to invest in training businesses or start their the second level of the poverty cycle is related to health challenges inability to afford preventive medication proper nutrition and a healthy living environment leads to health issues or challenges these factors contribute to the persistent disadvantage experienced by the poor moreover the poverty cycle means that due to inadequate income impoverished individuals fail to invest in their childrens education as a result children attend lowquality schools and fall further behind when entering the job market the third level of the poverty cycle is characterized by a lack of employment and income which leads to worsened selfconfidence weak motivation and depression the psychological problems of individuals are exacerbated by their interactions with others fostering a culture of despair in rural areas this culture of despair also affects community leaders leading to a sense of hopelessness and fatalism among them perception theory individuals behave in a certain way based not on the actual external environment but rather on what they see or believe perception therefore explains a process by which individuals organize and interpret their sensory impressions to give meaning to their environment the study of perception has long been conducted the study of perception is important in the analysis of organizational behavior because peoples behavior is based on their perception of reality not on reality itself the perceived world forms the basis for attitudes and behaviors when making decisions determinants that influence perception are related to the perceiver the perceived target and the situational environment in which objects people and events are perceived in the context of perception implemented in a social environment the concepttheory approach typically used is attribution theory attribution theory is a process in which individuals observe behavior and interpret whether the behavior is internally or externally caused internal attribution refers to behavior that is under the control of the individual conversely external attribution is related to behavior where the dominant influence is derived from external factors attribution theory will be used to analyze the perception of the impoverished community regarding alternative efforts other than main job the problem to be examined in this research is the relationship between socioeconomic and demographic characteristics with the poverty level measured by the income level of the population in the coastal and island regions of south sulawesi the coastal and island regions in south sulawesi generally share similarities in terms of socioeconomic and demographic factors however in certain aspects especially geographical location ethnicity and cultural influences the communities exhibit unique variations nevertheless this study focuses solely on the socioeconomic and demographic characteristics associated with income levels methodology the population in this study consisted of the entire poor population residing in coastal areas and islands in south sulawesi a total of 273 individuals were sampled from 5 selected regions makassar city pangkep district jeneponto district bulukumba district and selayar district the unit of analysis was poor households the data analysis method involved descriptive analysis to provide an overview of the characteristics of poor households and chisquare analysis to examine the relationship between the characteristics of poor households and various socioeconomic variables as well as the relationship between the perception of the poor community and alternative livelihoods result and discussion referring to the research objectives which aim to describe the demographic social and economic characteristics of households as well as analyze the relationship between the characteristics of poor households and income levels in 5 districts and cities in south sulawesi province the analysis and discussion of the research will be systematically presented as follows age characteristics the analysis of respondents based on age groups aims to differentiate whether respondents fall within the productive or nonproductive age range in this study it is assumed that the productive age group comprises individuals aged 18 to 50 years while the nonproductive age group includes those above 50 years characteristics of education looking at the level of formal education attained by the respondents the largest group consists of respondents who have not completed primary school accounting for 25 percent or 68 individuals this is followed by respondents with primary school education totaling 115 individuals or 42 percent of the total respondents the group with junior high school education comprises 51 individuals or 19 percent the smallest group is respondents with high school education or higher comprising 14 percent or 39 individuals for a clearer distribution of respondents based on education please refer to figure 2 main job characteristics of the 273 respondents selected as sample members in this study 5788 percent or 158 respondents whose main occupation was fisherman 30 people of respondents worked as farmers while 6 percent and 24 percent of the total respondents worked as traders and craftsmenservices for more details on the distribution of respondents according to education can be seen in figure 3 income characteristics among the selected respondents 20 percent or 56 individuals had an average income per family member below rp 1000000 per month additionally 62 respondents had an average family income ranging from rp 1000000 to rp 2000000 per month furthermore 35 percent of respondents had an average family income exceeding rp 3000000 per month this indicates that 56 families of respondents are living below the poverty line relationship between household head age and household per capita income the distribution of households based on the age of the household head tends to be concentrated in the productive age group with 289 percent and 264 percent further analysis using statistical tests reveals a significant difference in the proportion of household income based on the age of the household head this indicates a significant relationship between the age of the household head and household income with a pearson chisquare value of 0001 which is smaller than the significance level of 5 this suggests that among poor households the older the household head the more productive they are when this condition is associated with human capital theory it is evident that work experience has a positive impact on labor productivity the implication of these research findings is that the improvement of human capital among the poor population is still necessary relationship between household head education and household per capita income theoretical perspectives from anderson ehrenberg et al and mcconnell depict the relationship between education and annual income through graphs becker defines human capital as the knowledge possessed by individuals that enhances work productivity and in turn leads to receiving rewards assumed to be equal to the marginal productivity value this research supports the human capital theory where formal education is positively and significantly related to household per capita income upon further analysis a significant relationship is observed between the level of education and per capita income of poor households with a pearson chisquare value of 0002 smaller than the significance level of 5 this indicates that the level of education is an investment in human capital that needs to be developed to promote labor productivity which will subsequently lead to increased income or reduced poverty rates in society the findings of this research align with previous studies conducted by belzil wheeler bound and bloeman who found that education and work experience have a positive and significant impact on income levels this indicates that this research contributes to the scientific knowledge base particularly in the field of human capital theory thus the importance of education as a primary human capital asset becomes increasingly irrefutable alongside work experience and natural abilities as well as social environment in this case low income skills and low education are interconnected and mutually influential according to jalaludin rachmat low productivity and low income lead to low education low education results in lowquality human resources lowquality human resources lead to low productivity and the cycle continues this perspective is referred to as a vicious circle or the poverty cycle relationship between household head occupation and household per capita income the distribution of household heads based on per capita income and occupation shows that there are differences in the pattern of household per capita income based on occupation it appears that workers in the nonprimary sector have a higher chance of obtaining higher per capita income compared to the primary sector further analysis using statistical tests reveals a significant difference in per capita income among different occupations the statistical test results show a significant relationship with a pearson chisquare value of 0001 smaller than the significance level of 5 this indicates that the research findings support the theory that work productivity in the primary sector is relatively lower than in other sectors the primary sector is more susceptible to specific seasons and climate variations while the nonprimary sector is relatively less affected by time seasons and specific climates the poverty characteristics and alternative livelihoods for sustainable coastal communities in 5 districtscities in south sulawesi province including gender marital status family size age formal education informal education reading and writing skills proficiency in using the indonesian language primary occupation family per capita income family income home ownership status social activities assistance from external sources land ownership machinery ownership savings ownership boat ownership vehicle ownership and monthly expenses generally they have similar characteristics to the overall poor population in coastal communities farmers and urban areas in indonesia however there are variations and differences compared to previous studies particularly regarding the primary and secondary occupations which do not show a difference in terms of family income the relationship between these socioeconomic characteristics and family income levels can be summarized as follows in coastal poor communities the productive age is crucial for achieving better family income in order to sustain socioeconomic wellbeing in the future since coastal community occupations primarily rely on physical strength the labor force and the number of individuals greatly determine income output consequently the desire to have a with an increase in family size that is not proportionate to an increase in family income it will undoubtedly affect the level of economic wellbeing for the family formal education and informal education are also essential needs for coastal poor communities but the tradeoff between current consumption as a longterm capital investment forces them to prioritize the former this means that free education programs for the coastal poor community are their hope for government support active participation in various institutions is crucial for building character and motivating coastal poor communities to break the cycle of poverty however social activities do not have a significant impact on family income and are often avoided or not pursued at all various institutional and social activities are needed to have an impact on improving family economy having alternative secondary occupations in addition to the primary occupation as a coastal fisherman farmer trader or other service sectors should have a positive impact on increasing family income however the study results show no difference between the primary and secondary occupations this means that the secondary occupation is still part of the primary occupation and does not contribute to additional family income therefore alternative livelihoods beyond the primary occupation need to be developed alternative livelihoods in the service sector should be considered as the nonprimary sector has a greater opportunity to earn higher income compared to the primary sector efforts in that direction can be undertaken since coastal poor communities also have the same preferences as other communities in terms of developing human resources this means they can be educated and trained to expand their skills and knowledge leading to a wider range of job opportunities that can increase family income conclusion and suggestion the characteristics of poverty and alternative livelihoods in the sustainable coastal communities in 5 districtscities in south sulawesi province including age formal education main occupation and per capita family income exhibit similarities to those of the general poor communities in coastal areas inland areas and urban areas in indonesia among these characteristics age education and main occupation show a significant relationship with family income based on the findings it can be concluded that in coastal communities facing poverty the productive age group level of education and choice of occupation play crucial roles in determining a familys income these factors are essential for enhancing future socioeconomic wellbeing and ensuring the sustainability of the communitys socioeconomic conditions to address the challenges faced by coastal village communities in south sulawesi several recommendations can be made firstly it is crucial to provide accessible and free education services to these communities the government should develop a national education system that specifically caters to the needs of the coastal poor offering both formal and informal education opportunities currently education in indonesia is prohibitively expensive for many coastal families leading them to prioritize survival over schooling for their children by ensuring that education is affordable and accessible the government can empower coastal communities and provide them with the knowledge and skills needed for economic advancement another important aspect to consider is the redistribution of business ownership and

purpose this study aims to describe the characteristics of poor households including age education and main occupation and examine their relationship with the income level of poor households in coastal communities in south sulawesithe reality today still shows that these various poverty alleviation programs have not fully addressed the root causes of poverty in theoretical studies poverty is rooted in three main factors individual poverty cultural and environmental poverty and structural poverty designmethodologyapproach the research sample consisted of poor individuals living in coastal and island areas in south sulawesi with the unit of analysis being poor households the sample size was 273 people descriptive analysis was conducted to determine the general characteristics of poor households and chisquare analysis was used to assess the relationship between social characteristics and income levels findings through chisquare analysis it was found that age education and main occupation had a significant relationship with family income hence in poor coastal communities productive age education and occupation are crucial factors in achieving higher family income and maintaining socioeconomic welfare in the futurethe findings have practical implications for policymakers and practitioners working to reduce poverty in coastal communities the identified factors such as age education and occupation can guide targeted interventions including providing free education and promoting alternative livelihoods beyond traditional occupations originalityvalue this study offers valuable insights into the characteristics of poor households in coastal communities in south sulawesi and their relationship with income levels

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introduction modeling human mobility in a city is tightly related to geographical patterns and spatial distributions understanding individual movements brings useful insights for a variety of applications such as urban planning 1 security 2 migration studies 3 disease spread 4 traffic prediction 5 tourism 6 and recommender systems 7 researchers have tried to use surveys 8 from travel or tourist centers in a traditional way to study mobility patterns however thanks to new technologies finding a dataset to analyze peoples mobility is not a big concern anymore recently a significant effort has been made with different types of datasets including phone call records 9 wifi or rfid 1011 global positioning system 12 and locationbased social network 13 data in order to obtain useful information from geographical movements in this area researchers have tried to tackle various questions does human mobility follow any model or pattern is it possible to extract significant patterns to define mobility models is it possible to estimate trajectory via hometowork commutes do these trajectory patterns depend on the initial geographical position of individuals traditional survey records are based on questions and answers which require human resources and a lot of time to obtain and to be analyzed statistically on the other hand gps or cdr data have privacy limitations and lack a large amount of data more recently the explosive use of social media with geolocations shared by users launched new research fields using locationbased social networks like twitter facebook foursquare or the chinese microblog sina weibo revealing unique opportunities to track mobility behaviors these usergenerated data provide extensive knowledge in three dimensions namely space time and textual content then human mobility research can be accomplished using a different and complementary perspective depending on the goal of the analysis with the rapid improvement in technology and widespread use of smartphones in contrast to other sources of data more and more people use applications to share their moments with others this huge amount of checkin data can be considered as big data it contains not only geotagged data but also peoples social profiles enabling researchers to conduct a comprehensive study on geographical positions mobility behavior social connections or travel demands moreover the checkin data from social networking sites are publicly available in big sizes for example the chinese sina weibo microblog allows users to send texts photos and videos while sharing their location online according to the weibo industry research and development center 14 in the first half of 2018 the number of mobile microblog users in china was about 316 million showing an increase of 2923 million compared with the end of 2017 on the other hand recent findings in 15 have proven that china is one of the most rapidly developing countries thus city planners have focused more on implementing urban planning designs for spatial urban pattern development constructing a bridge between urban infrastructure layout and planning is a momentous objective therefore studying urban spatial schemes has gained huge attention aiming to design impactful commercial business districts in smart and sustainable cities the european regional cohesion policy determines capacity quality viability timeline and history and landscape as four dimensions of the objective of achieving all aspects of urban life through expert planning in smart metropolitan areas focusing on metropolitan spatial structures city planners play an important role in monitoring and managing a better and safer mobility topography economic development consumer preferences population growth and sustainable transportation such that all these factors together aim to improve the quality of inhabitants lives using technologies as an emerging tool to analyze the spatiotemporal aspects of human mobility in newly developed cities such as shanghai helps the government to better understand citizens needs and the heartbeat of movement in order to provide efficient traffic flow between movements due to supply and demand to achieve this aim it is important to identify the frequently congested regions in cbd areas and the reasons these areas are congested understanding citizens demands helps managers to make better decisions to spread and balance different types of services in all regions in order to maximize movement flow optimize resources and reduce congestion researchers have offered different descriptions of commercial central districts mccoll et al 16 described an area with a main centralization of business land use as cbd with a similar point of view to drozdz et al 17 who pointed out that a significant cbd area contains enormous financial activities following 18 we agreed that a cbd area contains a dense distribution of commercial resources and has highdensity road networks every open data source point of interest that represents an entity in the geographical space is a reflection of the cbd our main motivation here is to test the validity of geolocated weibo data as a means of elucidating human mobility and activity patterns in addition we aim to identify important places in peoples lives with the support of locationbased services in order to improve understanding of general human movement patterns and support the creation of realistic and practical models of human mobility we also tried to adopt a geotagged weibo dataset in order to analyze the behavioral characteristics of users from two perspectives namely their activity time and checkin point of interest types despite the different values of checkin social media data there are some issues that affect the quality of research in this field when using social networks an internet connection is required to allow users to share their posts and generate spatiotemporal data using the geolocation from where the user posts the message and the moment when they did however what if the user does not have an internet connection at the specific posting time the post will not have a tagged geolocation and time stamp and will not be useful for data analytics in addition a fake checkin happens when a user shares a location which is above the venue threshold of the actual location due to various reasons a user may share a post claiming they are enjoying food in a restaurant but in fact they have made the post staying at home thus fake checkin records should be excluded from the analysis in this paper we aim to analyze human mobility in the city of shanghai from spatiotemporal big data extracted from the chinese microblog sina weibo as a major city of china shanghai was chosen as the case study of this research applying several data analytics algorithms to validate the use of a oneyear period of weibo data as a means of discovering human mobility patterns the data available from the sina weibo dataset were enriched with a poi dataset to associate a more meaningful interpretation of the geolocation of each weibo post several questions were posed such as how does one find out significant locations in peoples lives as an important aspect of characterizing human mobility is there an impact due to gender differences how does one discover and describe mobility trajectories the remainder of this paper is organized as follows in section 2 relevant research work related to social media data analytics is presented section 3 gives a brief introduction of our case study and the dataset used in our analysis in activitybased mobility studies the generation of origindestination matrices for analyzing movement behavior is essential peoples movement is explored from an intraurban perspective to generate od travel matrices to identify trips from home to workplaces in section 4 we explain the details of the cleaning data in order to identify accurate od matrices section 5 presents the methodology applied and provides a detailed description of the algorithms implemented to detect trip patterns discover the most popular visited places explore the temporal dimension and estimate trajectories through the calculation of origindestination travel matrices in particular different groups of people were considered in the analysis of 11 different districts of shanghai the results obtained are visualized using adequate techniques to support decisionmaking related work human mobility refers to the movement of an individual or a group of people from their origin geolocation to their destination recently peoples mobility has become a hot topic not only for the academic community for fundamental research purposes but has also as an important research field for policymakers in smart cities in order to provide better services for citizens human mobility has become an interesting topic for different research fields ranging from computer science to social science 19 and geographical science 20 the concept can be applied to areas of study such as urban planning decisionmaking migration epidemic control and transportation services understanding human movement becomes a crucial research question and the purpose behind it is to integrate different data sources available for a variety of topics different topics can be obtained and analyzed from two perspectives of spatiotemporal analysis liu et al 20 worked on taxi trajectory data and introduced a number of point pair vectors they analyzed the population distribution assuming that each trip has two points a pickup point which was considered as the origin and a dropoff point considered as destination they applied the monte carlo method to shanghai data to validate their model in another study liang et al 5 showed that the average population who visits a zone in a city is a good data source to model human mobility and the resident population thus they calculated the daily population visiting a zone using a radiation model to predict the flows of crowds these two research works focused on the spatial distribution of flows however to highlight a difference with another research wu et al 21 calculated intraurban human mobility by combining activitybased and movementbased approaches and focused more on temporal variation compared to previous studies wu et al 21 used temporal properties to find out whether peoples activities were in a fixed area or not and introduced two different types of activities namely locationally mandatory activities and locationally stochastic activities since agentbased modeling techniques are good for capturing actions in a time series bonabeau et al 18 introduced different applications using abm related to dynamic human behavior patterns in the real world the most important fields for the application of flow studies include traffic human mobility management and evacuation the importance of this field is revealed when the number of crowd disasters rises a suitable system for supporting transport system planning based on peoples movement analysis would present the transportation network and simulate an individuals activity origin the destination of trips and timing properly a further step in this system would be to predict how the changes in peoples behavior and activity could affect trips and movement in cities another interesting application of human mobility analysis is for city management carpooling has been introduced in order to tackle some transportation problems in big cities with the goal of sharing part of the ride or expenses with other users human mobility analysis supports the implementation of mobility management policies to control the number of vehicles on the road furthermore it reduces traffic and co2 emissions and thus air pollution another interesting study was published by cezar 22 who worked on gps data to find the routine trips in pisa 23 and applied the densitybased clustering method to social media data to find out the number of users in different events like cultural and religious conferences or festivals and detect which ones attract a large number of people another useful data source to analyze peoples movement is call detailed record data cellular network providers collect the call records and text messages of each person to provide better services each cdr data contain the duration and location of each call as well as associated text messages if they are available these data can be used to obtain the location of the owner of a cell phone and according to several surveys cdr data are considered a better data source for instance isaacman et al 24 used cdr data to confirm individuals movements that can be detected by analyzing the footprint left by the user in the places they called from they chose hartigans leader algorithm 25 to cluster the cell towers which were first sorted in a descending order the reason they chose this algorithm is that it does not require the definition of the number of clusters in the analysis since the distance among cell towers in suburban areas is about 1 to 3 miles while in urban areas it is approximately 200 meters they found that one mile is an appropriate equalization of the two kinds of area moreover logistic regression was applied to determine the likelihood of the importance of a cluster nowadays due to the easy use of social media services like foursquare twitter facebook and sina weibo especially on phones they have become very popular and have attracted the attention of researchers there are billions of people who use social media to share their knowledge ideas daily life routines and photos while sharing their location these locationbased services not only attract peoples attention towards sharing their experiences but also allow researchers to take advantage of this significant source of data for analyzing peoples behavior cheng et al 26 collected checkin records from 220000 users from different sources of location sharing services to analyze aspects of spatiotemporal and textual mobility patterns they proposed different ideas based on the density of the datasets in new york city los angeles and amsterdam they found out that human mobility is influenced by economic and geographical constraints and sentiment analysis of text messages enriched understanding of their research ullah et al 27 also analyzed spatiotemporal data from lbsns to show the impact of people in green spaces yan et al 28 investigated three different datasets including sina weibo data to analyse individuals decisionmaking regarding the places they tend to go and the influence of the economic aspects of crowds on hot spot destinations they proved that the gravity model is wellsuited to predicting the effects of mobility on destinations they believe the results are applicable for decisionmaking policies in another research liu et al 29 focused on examining the mobility differences between four different communities of wuhan city based on sina weibo data they classified communities according to their checkin activities at specific areas and investigated their spatiotemporal behavior in six groups of categories wang et al 30 analyzed the relationship between human trajectory and weibo access locations additionally combining mobile phone records they first classified the locations visited by users based on phone records and then found out the most frequently visited places by the weibo distribution data they concluded that time and speed patterns are beneficial for the classification of trajectories in a similar work chao et al 31 studied sina weibo data to analyse students activities on campus using the chinese university of geosciences wuhan community as a case study they found out the influence of distance on students spatiotemporal mobility patterns differing by the gender of users they made a comparison of the results they discovered that the community in their research tended to make more weibo posts related to entertainment activities in another work hasan et al 32 analyzed a twitter dataset to categorize the spatiotemporal dimension of mobility patterns categorizing peoples activity was addressed in this research illustrating the frequency of visited popular places kernel density estimation 33 was used to find out the distribution of activities over three major cities in the us by splitting the temporal aspect into 3 hour intervals they discovered that people choose their destination based on the popularity of visited places not randomly moreover there is a greater likelihood of making a destination based on the influence of other users that have selected the same place before and shared their experiences through social media one year later hasan et al 34 worked more on social media checkin data from twitter to classify individual activity patterns they applied the latent dirichlet allocation 35 algorithm to find the distribution of specific words in tweets that represent home and working places yilan et al 36 proposed a threestep methodology first in order to find the unique venues they applied a distancebased clustering algorithm on days of the checkin records instead of the total number of users checkin they used a distancebased clustering algorithm to discover the unique venues then filtered the important clusters by frequently visited places in total days and finally find out the work and home places which were labeled based on checkin records and poi data a gravity model provides an estimate of the volume of flow for example goods services or people between two or more locations this could be the movement of people between cities or the volume of trade between countries gao et al 37 proved that checkin data are a suitable and efficient model to predict human mobility using their gravity model despite some other research works 29 where authors believe the gravity model 30 is not wellfitted to elucidate spatial interactions in order to solve the challenge of low graph density they used the particle swarm optimization method to obtain the best fit they revealed the underlying distance of interurban travel demand based on social media checkin data and flight passenger data recently many efforts have been made to analyze human mobility from very distinct datasets a great effort has been made to review recent works in 38 different methods and models have been used to understand human movement the gravity model is one of the most used models for analysis in this regard since the gravity model is static the parameters must be adjusted with real mobility data from additional sources of data beiro et al 39 designed a hybrid model with a classical gravity model by training a real dataset from flickr to find peoples traces in the us as a summary different data types and methods used for human mobility analysis are presented in table 1 in addition to previous approaches there are also research works on human mobility for geographical studies and urban planning whose goal is to find peoples important places of movement and specifically to analyze their mobility between home and work with the purpose of location tracking this kind of analysis allows the creation of origindestination matrices there are three categories for od matrices that can be useful in transportation applications collecting data for od household surveys in a traditional way is timeconsuming does not provide continuous data and is basically for a specific study area another method is countbased od from traffic detectors although this method reduces estimation time and expenses it has a high cost in terms of installing infrastructure on roads plus it presents coverage issues with the emergence of new technology new sources of data have been introduced to collect traffic flow data such as gps and bluetooth data which both have their own limitations for example due to privacy concerns when collecting users trajectory data by gps the users agreement is required and since users tend to turn off bluetooth on their devices to save battery this influences the sample rate lbsn services overcome all these limitations in the era of new technologies as a dynamic mobility solution yang et al 40 obtained an od matrix using a novel mixed combining regression and gravity model using foursquare checkin data they classified eight categories of venues using an agglomerative hierarchical clustering method using chicago metropolitan agency for planning data helped to compare and evaluate their model estimating od travel matrix for noncommunity trips in another study wang et al 41 worked with taxi gps data to obtain travel patterns from od flows they proposed a chord diagram plot to illustrate the spatiotemporal patterns of residents in sevenday taxi trajectories in beijing data type pros cons traditional survey 8 multipurpose usage a human source is required timeconsuming not accurate and static wifi 10 energy usage is 50 of gps low coverage area gps 12 more precise and can distinguish between transportation modes high energy usage signal problems and expensive cdr 20 autogenerated lack of a big data size and privacy issues social media 33 cheap easy access big size challenges in extracting useful insights in another work kurkcu et al 42 proposed a densitybased clustering algorithm elucidating the most common human mobility features of hometowork travel validating twitter data as a ubiquitous and suitable data source to elucidate travel demands identifying home places they clustered the most visited locations of a user based on the number of tweets and assumed the most visited place as a home or origin in addition to time filtering they applied some keyword filters on tweets to verify the origin of a users trip based on those conditions they chose the strongest density as a home place for a given user their research shows that twitter data are a potential suitable source of data to analyze activity patterns on the other hand xuan et al 43 analyzed different groups behavior using the smart card data of shenzhen combined with social media data focusing on students and travelers they revealed useful insights into travel flows in both aspects of the spatial and temporal characteristics they applied the kmeans algorithm to divide travelers into different groups and check their specific temporal activities on different days of the week the results show a major hub in the metro system based on the number of tapin and tapout times in the dataset all these works have shown the relevance and potential of using geolocated data from different sources to analyze human mobility in particular this confirms the interest in exploiting social media data in this regard in this paper a selected number of algorithms inspired by previous works are implemented to discover human patterns starting from traditional statistical analysis and progressing to dynamic data analysis of social media materials a description of the data used in this study and their main features are presented in this section explaining their origin and characteristics in particular a description of the sina weibo dataset is provided as well the shanghai poi dataset case study shanghai is one of four municipalities under the direct administration of the central government of the peoples republic of china the city is located on the yangtze river on the east coast of china shown in figure 1 the municipalitys area includes the city itself surrounding suburbs and an agricultural hinterland shanghai is chinas most populous city covering a land area of 63405 square kilometers with 241970 million inhabitants living in 16 districts at the end of 2016 according to the 2017 shanghai statistical yearbook isprs int j geoinf 2020 9 125 7 of 33 in 2017 16 districts constituted the city of shanghai chongming is the largest island and has an area of 489 square miles the pudong district was originally established in 1958 the district borders the huangpu river separating it from the central business district of puxi pudong is one of the earliest industrial areas hongkou district is another important industrial area that lies to the north east of the suzhou river in 2017 16 districts constituted the city of shanghai chongming is the largest island and has an area of 489 square miles the pudong district was originally established in 1958 the district borders the huangpu river separating it from the central business district of puxi pudong is one of the earliest industrial areas hongkou district is another important industrial area that lies to the north east of the suzhou river isprs int j geoinf 2020 9 125 7 of 33 in 2017 16 districts constituted the city of shanghai chongming is the largest island and has an area of 489 square miles the pudong district was originally established in 1958 the district borders the huangpu river separating it from the central business district of puxi pudong is one of the earliest industrial areas hongkou district is another important industrial area that lies to the north east of the suzhou river dataset following an approach that explores geolocated social media data this paper combines different sources of data to analyze human mobility these sources of data include sina weibo data to detect geolocations corresponding to home and work locations and to enrich the analysis pois are also used to illustrate destinations frequented by people first we present the original dataset then we describe how the data were delimited into selected boundaries and how they were combined with the poi database sina weibo data the initial data were collected from the microblog network sina weibo using the baidu api sina weibo is a microblogging social media platform that is considered as the chinese version of twitter as western social media platforms like facebook twitter and youtube are blocked in china as the second most popular site in china it provides media and news updates and users can follow their favorite celebrities a mckinsey survey reported that 95 percent of chinese people use sina weibo in their everyday lives compared to 70 percent in south korea and 67 percent in the united states 44 in q1 2018 it was reported that there was a 207 increase over the last year in use of weibo which had reached 411 million monthly active users opening a potential data source to analyze movement patterns data were collected in the period of 2014 and 2015 with a total of 325713 weibo posts in the whole dataset covering a part of china considering the importance of shanghai as a cosmopolitan city and the financial center of china we focus here on data belonging to this city the number of weibo posts belonging to shanghai city is 248339 table 2 shows a short description of our dataset each record of the data contains different types of information about users such as their user id gender location time message etc after storing and filtering data we used ogis for visualization table 2 shows the initial dataset statistics as table 2 shows the original dataset comprises 325713 checkins and after data preprocessing it was reduced to 248339 checkins the cleaning and preprocessing stages applied to the source data are described with more detail in section 4 boundaries data in order to understand the spatial aspect of checkins we used shapefiles representing the administrative area boundaries of shanghai to determine the district from which the weibo posts were published the resources were taken from an open geodata source called global administrative areas gadm is a highresolution database of administrative areas for all countries in the world at all levels of subdivision administrative areas in this database include countries provinces departments counties etc for each area it provides some attributes like name variant names and spatial features about the location of the areas the gadm data are publicly available to be downloaded by country or the whole world in different formats such as shapefile rdata google earth kmz format and esri geodatabase the gadm database allowed us to confirm the origin from which the sina weibo posts were published figure 3 shows the number of published weibo posts in 16 districts within shanghai points of interest in addition to the sina weibo dataset we used a poi dataset the definition of a point of interest is a specific physical location that someone may find interesting such as a restaurant retail store hospital bank etc some researchers have classified travel demand for intraurban human mobility by poi data 45 in a similar approach this work first used the baidu api to translate chinese text into english and validate it with a chinese native speaker figure 4 shows an example of the source poi data that were completed with the english translation for the category and name of the place focusing only on jiading district then knowing the poi activity we classified the poi data into eight different categories including dining education center schools points of interest in addition to the sina weibo dataset we used a poi dataset the definition of a point of interest is a specific physical location that someone may find interesting such as a restaurant retail store hospital bank etc some researchers have classified travel demand for intraurban human mobility by poi data 45 in a similar approach this work first used the baidu api to translate chinese text into english and validate it with a chinese native speaker figure 4 shows an example of the source poi data that were completed with the english translation for the category and name of the place focusing only on jiading district isprs int j geoinf 2020 9 125 9 of 33 points of interest in addition to the sina weibo dataset we used a poi dataset the definition of a point of interest is a specific physical location that someone may find interesting such as a restaurant retail store hospital bank etc some researchers have classified travel demand for intraurban human mobility by poi data 45 in a similar approach this work first used the baidu api to translate chinese text into english and validate it with a chinese native speaker figure 4 shows an example of the source poi data that were completed with the english translation for the category and name of the place focusing only on jiading district then knowing the poi activity we classified the poi data into eight different categories including dining education center education center entertainment healthcare residential services transportation and work places table 3 shows statistical results providing insight into the different categories the statistical results in table 3 indicate that the entertainment category attracted the greatest number of users followed by the transportation category the highest average of checkins belongs to the work places category figure 5 shows the distribution of pois organized by category considering their geolocation in the different districts of shanghai most pois belong to the services category followed by education centers and residential areas the smallest amount of pois corresponds to the transportation and healthcare categories different colors illustrate the concentration of each category of poi in each district of the city of shanghai isprs int j geoinf 2020 9 125 10 of 33 universities kindergartens libraries institutes entertainment healthcare residential services transportation and work places table 3 shows statistical results providing insight into the different categories the statistical results in table 3 indicate that the entertainment category attracted the greatest number of users followed by the transportation category the highest average of checkins belongs to the work places category figure 5 shows the distribution of pois organized by category considering their geolocation in the different districts of shanghai most pois belong to the services category followed by education centers and residential areas the smallest amount of pois corresponds to the transportation and healthcare categories different colors illustrate the concentration of each category of poi in each district of the city of shanghai data preparationpreprocessing in order to get a reliable and consistent dataset before data can be further explored using data analysis techniques the raw data were converted into an appropriate format to ensure that they data preparationpreprocessing in order to get a reliable and consistent dataset before data can be further explored using data analysis techniques the raw data were converted into an appropriate format to ensure that they belonged to the space and period of interest in order to prevent the inclusion of biased results a set of scripts was developed in the python programming language ready to be applied to the dataset all steps and transformations applied are described in the following subsections data cleaning in this part of the process incorrect data were detected filtered and corrected in order to prevent false conclusions the preprocessing consists of filtering out irrelevant columns removing duplicate rows resolving inconsistencies and performing data harmonization allowing better data interpretation in the analysis process after deleting nine columns of data that did not contain related content we were left with 48594 unique users and a dataset size of 248339 weibo posts filtering checkin records fake checkins exist despite some mechanisms to prevent them in social media services they may happen when a user chooses a geotag for a post when in fact it does not exist or they are not there the place or location from where tweets or messages are sent is assumed to be home here in our analysis we assumed that a place or location from which the user posted a weibo or the location from where most messages are sent during nonworking times is the home in order to detect origins and destinations and eliminate fake checkins we filtered the data since the data have two aspects of space and time a major filter was applied to each aspect • temporal filtering for the time feature we assumed those users who published only within a period of 10 days were possibly tourists moreover we extracted the relationship of different checkin timestamps to calculate checkin duration considering the start and end time we also created a timestamp for each published weibo adding the day of the week to better analyze the temporal feature • removing spatial outliers from the data the outliers here are defined as extreme values not relevant to the current study area considering the location we chose weibo posts that had been published within the area of our case study taking into account the territorial boundaries as shown in figure 6 on the other hand to find users who usually send messages from a similar location we filtered the users with an average distance of less than 50 m by calculating the distances of the dispersion deviation of each user only about 100 weibo posts were excluded and some of them came from the shore of shanghai additional filtering the purpose of adding more filters to our analysis was to increase the quality of data and to work with more relevant data additional filters were applied in order to produce precise results from this analysis • different accounts identified by the same user id were eliminated we removed any user id with more than 100 weibo posts per day at the same location considering it to be a bot account • in order to find users who have very little activity among the users in the case study we eliminated those who have published only five weibo posts identifying users with low activity • users with 4 days or less of consecutive checkins were also erased according to the above criteria the final checkin records totaled 233467 weibo results we used these data in the next step to extract meaningful insights into our research data transformation in order to take advantage of the collected data new fields were generated using the poi and boundary datasets giving as a result a whole enriched dataset the fields that were added were • day of week determined by mapping between timestamp and chinese calendar • district name determined from the gps location column and boundaries dataset • district of publication determined from the gps location column and boundaries dataset • activity category determined using the nearest poi methodology and results the research follows the lifecycle of an average data analysismining project it starts by formulating questions then moves on collecting the data preprocessing the data exploring the data and communicating the data findings figure 7 shows the steps of the methodology applied additional filtering the purpose of adding more filters to our analysis was to increase the quality of data and to work with more relevant data additional filters were applied in order to produce precise results from this analysis • different accounts identified by the same user id were eliminated we removed any user id with more than 100 weibo posts per day at the same location considering it to be a bot account • in order to find users who have very little activity among the users in the case study we eliminated those who have published only five weibo posts identifying users with low activity • users with 4 days or less of consecutive checkins were also erased according to the above criteria the final checkin records totaled 233467 weibo results we used these data in the next step to extract meaningful insights into our research data transformation in order to take advantage of the collected data new fields were generated using the poi and boundary datasets giving as a result a whole enriched dataset the fields that were added were • day of week determined by mapping between timestamp and chinese calendar • district name determined from the gps location column and boundaries dataset • district of publication determined from the gps location column and boundaries dataset • activity category determined using the nearest poi methodology and results the research follows the lifecycle of an average data analysismining project it starts by formulating questions then moves on collecting the data preprocessing the data exploring the data and communicating the data findings figure 7 shows the steps of the methodology applied exploratory analysis and visualization in our experiments we divided the analysis into different sections in this section we investigate and compare the statistical analysis regarding the sine weibo data from between 2014 and 2015 from 11 districts of shanghai including the cbd area after cleaning the data we obtained 233467 checkin geotagged results and analyzed these from different perspectives as explained below • gender perspective regarding the analysis of different communities we analyzed the data based on gender the results in figure 8 show female and male activities in two periods of time from 2014 and 2015 we found that in both years females were more active than males analyzing the total checkin numbers differentiated by gender we found that sina weibo as a social media platform is more popular among females with 22 more female users than males exploratory analysis and visualization in our experiments we divided the analysis into different sections in this section we investigate and compare the statistical analysis regarding the sine weibo data from between 2014 and 2015 from 11 districts of shanghai including the cbd area after cleaning the data we obtained 233467 checkin geotagged results and analyzed these from different perspectives as explained below • gender perspective regarding the analysis of different communities we analyzed the data based on gender the results in figure 8 show female and male activities in two periods of time from 2014 and 2015 we found that in both years females were more active than males analyzing the total checkin numbers differentiated by gender we found that sina weibo as a social media platform is more popular among females with 22 more female users than males • temporal perspective in order to find the peak hour of activities and the patterns of human mobility we analyzed the data based on time we analyzed the data of two different periods of the years separately and found that the activity trend was almost the same thus we merged the data of the two year period and illustrated the results in figure 9 despite other studies that have analyzed mobility based on periods of time we chose hourly movement to figure out more details because of the rapid movement of people and because we believe that people do not stay in one place for several hours and checkin several times the horizontal axis represents the time of day starting from midnight and moving to 11 pm and the vertical axis shows the number of checkins at that specific time or hour the distribution of checkins for females and males is denoted by two different colors first we sorted the time series in descending order by each hour timestamp then checked the user checkins in those series by gender ∈ where denotes the set of time t per day d for the group of users u by gender the results show that both females and males are more active at the end of working days in the period of 1800 to 2100 while fewer activities happened between 1100 to 1400 which are considered as lunch and resting times during working days however it was also observed that the checkin frequency of females was almost consistent with a slight increase during the day while it was the opposite for males in the same period of time • temporal perspective in order to find the peak hour of activities and the patterns of human mobility we analyzed the data based on time we analyzed the data of two different periods of the years separately and found that the activity trend was almost the same thus we merged the data of the two year period and illustrated the results in figure 9 despite other studies that have analyzed mobility based on periods of time we chose hourly movement to figure out more details because of the rapid movement of people and because we believe that people do not stay in one place for several hours and checkin several times the horizontal axis represents the time of day starting from midnight and moving to 11 pm and the vertical axis shows the number of checkins at that specific time or hour the distribution of checkins for females and males is denoted by two different colors first we sorted the time series in descending order by each hour timestamp then checked the user checkins in those series by gender p dt u ∈ where p dt u denotes the set of time t per day d for the group of users u by gender the results show that both females and males are more active at the end of working days in the period of 1800 to 2100 while fewer activities happened between 1100 to 1400 which are considered as lunch and resting times during working days however it was also observed that the checkin frequency of females was almost consistent with a slight increase during the day while it was the opposite for males in the same period of time • spatial perspective based on the analysis it is clear that human activities vary over time but it is of great significance to analyze human mobility in different regions for this reason we analyzed user activities in different districts to illustrate spatial dependencies the goal here is to help urban authorities who hope to understand human mobility patterns in different regions within the city figure 10 shows human activities based on 11 districts of shanghai from 2014 and 2015 from figure 10 it is obvious that yangpu is the most famous district among users because it is now the location of the city hall the bund and the most famous shopping malls and tourist sites • spatial perspective based on the analysis it is clear that human activities vary over time but it is of great significance to analyze human mobility in different regions for this reason we analyzed user activities in different districts to illustrate spatial dependencies the goal here is to help urban authorities who hope to understand human mobility patterns in different regions within the city figure 10 shows human activities based on 11 districts of shanghai from 2014 and 2015 from figure 10 it is obvious that yangpu is the most famous district among users because it is now the location of the city hall the bund and the most famous shopping malls and tourist sites table 4 shows the most visited districts in shanghai among these top six districts five are located in the cbd area of shanghai table 4 the six highest density districts from the two years • spatiotemporal perspective moreover for further and indepth analysis we investigated big geodata and applied mining techniques to discover knowledge concerning spatiotemporal relations as shown in figure 11 we analyzed the checkin activities at different hours of the day and compared the two years of data for seven districts of shanghai considered as a cbd the horizontal axis represents the time of day starting from midnight and moving to 11 pm and the vertical axis shows the number of checkins at that specific time or hour the distribution of checkins is denoted in eleven districts of shanghai including the cbd area and its four neighboring districts which are shown in a different color isprs int j geoinf 2020 9 125 17 of 33 • spatiotemporal perspective moreover for further and indepth analysis we investigated big geodata and applied mining techniques to discover knowledge concerning spatiotemporal relations as shown in figure 11 we analyzed the checkin activities at different hours of the day and compared the two years of data for seven districts of shanghai considered as a cbd the horizontal axis represents the time of day starting from midnight and moving to 11 pm and the vertical axis shows the number of checkins at that specific time or hour the distribution of checkins is denoted in eleven districts of shanghai including the cbd area and its four neighboring districts which are shown in a different color the analysis shows that people tend to publish more weibo posts within the period of 1100 to 1400 h which is considered as a lunch and resting time each color shows a different district and the size of the graphic reflects the number of weibo posts posted in that district we can see that the the analysis shows that people tend to publish more weibo posts within the period of 1100 to 1400 h which is considered as a lunch and resting time each color shows a different district and the size of the graphic reflects the number of weibo posts posted in that district we can see that the trends are almost the same over the two years there are clear increases in the number of weibo posts posted during the lunchtime break period and when people are normally back home at night kernel density estimation as discussed above the temporal information of movement in geographical space is important to detect the spatiotemporal trends of underlying human mobility however with the increasing number of aggregated humanvehicle trajectories in urban space the spacetime path representation model will be hard to interpret because of the overlapping and cluttering issues to solve this problem we applied the kernel density estimation 46 which has been widely used in spatial analysis to characterize a smooth density surface that shows the geographic clustering of point or line features in 2d space kde is a nonparametric algorithm used to calculate the density of features in a given dataset applying kde helps us to create a smooth curve in a given dataset and find the strongest density which represents the most important places in peoples lives kde is formulated as follows f 1 n n i1 k h 1 nh n i1 k x x i h 2 where h is bandwidth and n is the number of points the bandwidth affects the smoothness of the resulting distribution with the kernel function k this algorithm weights the points in each location to calculate the distance the bandwidth has a direct influence on the shape of the curve meaning that the bigger the value of the bandwidth parameter the smoother the curve which contains more points since we applied kde we can show a curve line showing the underlying distribution which is expressed as pk y x i h as shown in equation k is the kernel function estimate of the density at a point y within a group of points x i and i 1 n and h is the bandwidth we used kde to find the nearest neighbor here the process consists of finding the poi nearest neighbor to each user status using an efficient spatial search algorithm called kdtree which creates a binary search tree to match against the lookups which is carried out quickly reducing the search time to o where d is the number of dimensions if a poi is within a predefined umbral then we associate the activity category to the users status the kdtree algorithm consists of partitioning the space along one dimension at a time finding the median of the data that conform with the selected dimension splitting the data based on the median and changing the axis in a cyclic fashion at each partitioning step until in each partition we have the highest m number of points in each partition as shown in figure 12 most user activities are located in the center of shanghai or more specifically in seven districts including jingan hongkou huangpu xuhui and putuo which are considered as central business districts focusing on these specific areas we analyzed the mobility of people in different aspects first in order to remove noise and achieve smoother data we applied the densitybased spatial clustering of applications with noise algorithm densitybased spatial clustering of applications with noise spatial clustering analysis is a wellknown data mining technique it groups objects into clusters according to their similarities in both the location and attribute aspects dbscan 47 was used in this study we used the dbscan algorithm to find clusters of important locations in the users mobility which are densely connected in the region given in the dataset as a clustering method dbscan can remove noise on a set of points and verify whether based on the euclidean distance a group of points are close to each other two main parameters are required by dbscan • epsilon in order to find close neighborhood points eps is established as the maximum distance needed between points to define a cluster • min points this parameter denotes the minimum number of points to shape a cluster for example if eps is equal to 05 meters and minpts is equal to 7 dbscan will start with a random point and discover the seven points around its region of up to 05 meters forming the first cluster and if it could not find the minimum number of points to define the dense region it would consider this random point as noise we chose 5 of users published weibo posts in the dataset as minpts with a 200meter esp value choosing a suitable value for eps is crucial because if the value is too high the majority of the points will be merged in a same cluster while on the other hand if a small value will be selected for eps there will not be enough points for the cluster or it will not see the minimum number of points and thus it will be considered as noise a kdistance graph can be used to find a suitable eps value in the implementation of the dbscan algorithm the data were filtered and users that had less than or equal to 20 weibo posts were chosen we set the parameters of dbscan to find five samples within 500 meters to make a cluster figure 13 shows an example of the clustering with dbscan densitybased spatial clustering of applications with noise spatial clustering analysis is a wellknown data mining technique it groups objects into clusters according to their similarities in both the location and attribute aspects dbscan 47 was used in this study we used the dbscan algorithm to find clusters of important locations in the users mobility which are densely connected in the region given in the dataset as a clustering method dbscan can remove noise on a set of points and verify whether based on the euclidean distance a group of points are close to each other two main parameters are required by dbscan • epsilon in order to find close neighborhood points eps is established as the maximum distance needed between points to define a cluster • min points this parameter denotes the minimum number of points to shape a cluster for example if eps is equal to 05 meters and minpts is equal to 7 dbscan will start with a random point and discover the seven points around its region of up to 05 meters forming the first cluster and if it could not find the minimum number of points to define the dense region it would consider this random point as noise we chose 5 of users published weibo posts in the dataset as minpts with a 200meter esp value choosing a suitable value for eps is crucial because if the value is too high the majority of the points will be merged in a same cluster while on the other hand if a small value will be selected for eps there will not be enough points for the cluster or it will not see the minimum number of points and thus it will be considered as noise a kdistance graph can be used to find a suitable eps value in the implementation of the dbscan algorithm the data were filtered and users that had less than or equal to 20 weibo posts were chosen we set the parameters of dbscan to find five samples within 500 meters to make a cluster figure 13 shows an example of the clustering with dbscan one of the major challenges in analyzing lbsn data is the bias in human mobility because users can update their location at any time and place at home or work by applying dbscan we found the most important places in the users mobility and consider the strongest location of a user that is the densest area with the most points as home since people have more free time at home and we believe that there is a relationship between free time and posting on weibo the results were verified with the spatiotemporal aspects of published weibo posts for the spatial aspect we explored the longitude and latitude of each district in addition to the boundary data for the temporal aspect in each district we assumed that the time period between 6 to 11 pm during monday to saturday representative of home activities however we eliminated values larger than 10 miles and lower than 01 miles due to the limitation of boundaries in the study area as shown in figure 13 the results were verified randomly by checking the users profile where they chose their residential district while creating their account figure 14 shows a general view of total movement between districts in general view indegree mobility was calculated by the percentage of sum of all weibo posts from noncbd districts divided to the total number of weibo posts and outdegree mobility is the percentage of number of weibo posts from all cbd districts divided by total number of weibo posts and in order to give better detail of the idea of mobility we visualized the statistical results as well as the geospatial map separately for each district for the users whose home was in the same district and had checkins during the day time from 800 am to 600 pm in the cbd area to do so we should calculate the displacement metrics we investigated the displacement between users iterative checkins representing the mobility distance between the users likely home locations one of the major challenges in analyzing lbsn data is the bias in human mobility because users can update their location at any time and place at home or work by applying dbscan we found the most important places in the users mobility and consider the strongest location of a user that is the densest area with the most points as home since people have more free time at home and we believe that there is a relationship between free time and posting on weibo the results were verified with the spatiotemporal aspects of published weibo posts for the spatial aspect we explored the longitude and latitude of each district in addition to the boundary data for the temporal aspect in each district we assumed that the time period between 6 to 11 pm during monday to saturday representative of home activities however we eliminated values larger than 10 miles and lower than 01 miles due to the limitation of boundaries in the study area as shown in figure 13 the results were verified randomly by checking the users profile where they chose their residential district while creating their account figure 14 shows a general view of total movement between districts in general view indegree mobility was calculated by the percentage of sum of all weibo posts from noncbd districts divided to the total number of weibo posts and outdegree mobility is the percentage of number of weibo posts from all cbd districts divided by total number of weibo posts and in order to give better detail of the idea of mobility we visualized the statistical results as well as the geospatial map separately for each district for the users whose home was in the same district and had checkins during the day time from 800 am to 600 pm in the cbd area to do so we should calculate the displacement metrics we investigated the displacement between users iterative checkins representing the mobility distance between the users likely home locations although the gravity model is the most commonly used method to estimate the distance of consecutive checkins there are some limitations that need to be balanced as mentioned in 30 therefore following the previous studies 48 we proposed the haversine formula to compute the great circle distance between a pair of points by feeding the longitude and latitude of two published weibo posts within a threehour interval into the equation below 2 2 cos cos 2 where r is the radius of earth φ is longitude and is latitude at each threehour interval the displacement is calculated by dividing the sum of the displacements by the total number of unique users then where indicates the average displacements from two period of time and ∆ for each day di the term represents the displacements for users contributing in each day and at specific time intervals in this study a ∆ value of 3 hours was used to calculate the mobility between districts as shown in the equation the average displacement is calculated by dividing the summation of all displacements by the total number of users and the results of this are shown in figure 15 the geopy python package was used to run the code and calculate the distance between weibo posts we made four groups for the four neighboring districts of baoshan pudong minhang and jiading that include users whose home belongs within the longitude and latitude of each district we investigated the mobility of users in days of week to the central business district as shown in figure 15 although the gravity model is the most commonly used method to estimate the distance of consecutive checkins there are some limitations that need to be balanced as mentioned in 30 therefore following the previous studies 48 we proposed the haversine formula to compute the great circle distance between a pair of points by feeding the longitude and latitude of two published weibo posts within a threehour interval into the equation below c 2r arcsin       sin 2 ϕ 2 ϕ 1 2 cos cossin 2 λ 2 λ 1 2       4 where r is the radius of earth ϕ is longitude and λ is latitude at each threehour interval the displacement is calculated by dividing the sum of the displacements by the total number of unique users then d d i t p            d i t p∆t d i t p s dt d i t p∆t d i t p u dt            where d d i t p indicates the average displacements from two period of time t p and t p∆t for each day d i the term s dt represents the displacements for u dt users contributing in each day and at specific time intervals in this study a ∆t value of 3 hours was used to calculate the mobility between districts as shown in the equation the average displacement is calculated by dividing the summation of all displacements by the total number of users and the results of this are shown in figure 15 the geopy python package was used to run the code and calculate the distance between weibo posts standard deviational ellipse the standard deviational ellipse was proposed by baojun to analyze the distribution characteristics of discrete point data considering a rotated ellipse with a long axis that denotes the main orientation distribution 49 there are some sde functions available in software for example arcgis used to analyze spatiotemporal data which helps to visualize the orientation distribution ellipse of discrete points of data as an effective tool it visualizes a realistic model for human movement with less sensitivity to outliers it had been used for research fields such as the geo analysis field 50 at a detailed level we also used this helpful method to investigate human mobility tagged with travel demand as shown in figure 16 the major movement of people is along the cbd area in the westeast direction the eccentricity of the ellipse is larger in the period of 4 to 8 pm and decreases gradually by night from the period between 10 pm and midnight it is tightly connected to the geographic distribution of the citys infrastructure because the cbd area which is also called puxi is bisected by the huangpu river on the west part connecting with the east part of river by the pudong new area where one of the major tourist attractions is located we made four groups for the four neighboring districts of baoshan pudong minhang and jiading that include users whose home belongs within the longitude and latitude of each district we investigated the mobility of users in days of week to the central business district as shown in figure 15 standard deviational ellipse the standard deviational ellipse was proposed by baojun to analyze the distribution characteristics of discrete point data considering a rotated ellipse with a long axis that denotes the main orientation distribution 49 there are some sde functions available in software for example arcgis used to analyze spatiotemporal data which helps to visualize the orientation distribution ellipse of discrete points of data as an effective tool it visualizes a realistic model for human movement with less sensitivity to outliers it had been used for research fields such as the geo analysis field 50 at a detailed level we also used this helpful method to investigate human mobility tagged with travel demand as shown in figure 16 the major movement of people is along the cbd area in the westeast direction the eccentricity of the ellipse is larger in the period of 4 to 8 pm and decreases gradually by night from the period between 10 pm and midnight it is tightly connected to the geographic distribution of the citys infrastructure because the cbd area which is also called puxi is bisected by the huangpu river on the west part connecting with the east part of river by the pudong new area where one of the major tourist attractions is located in order to answer one of the purposes of this study that is to elucidate peoples interests or reasons to move to other districts we focused our analysis on the total movement of each of four neighbor districts namely baoshan jiading minhang and pudong to the cbd area and toward the points of interest in each district the results are shown in figure 17 in order to answer one of the purposes of this study that is to elucidate peoples interests or reasons to move to other districts we focused our analysis on the total movement of each of four neighbor districts namely baoshan jiading minhang and pudong to the cbd area and toward the points of interest in each district the results are shown in figure 17 in order to answer one of the purposes of this study that is to elucidate peoples interests or reasons to move to other districts we focused our analysis on the total movement of each of four neighbor districts namely baoshan jiading minhang and pudong to the cbd area and toward the points of interest in each district the results are shown in figure 17 from the figures we can understand the following facts that prove the validity of geotagged social media data 1 transportationrelated activities are bold in putuo from the neighbor district and are less than in pudong and this is reasonable because there is a major airport located in pudong 2 it can be observed that fewer people move from baoshan to the cbd in spite of pudong the reason for this is that the population and land area of baoshan are smaller and more people move from pudong 3 education activities mostly happen in yangpu 4 another interesting result is that from each neighbor district the mobility is increased in the border district compared to districts further away for example less mobility is seen from baoshan to xuhui or changning moreover another interesting result achieved by this analysis is the confirmation of different spatial patterns of people moving towards points of interest in the cbd area of shanghai our data demonstrated the tropism of travel in eight categories of the seven districts as shown in figure 18 there is a matrix for each trajectory denoted as txy where x ∈ 123 … 7 categories of points of interests and y ∈ 123 … 8 districts txy in each district represents the travel distance in that specific boundary of the region within a time interval that we chose namely two hours which we considered to be representative for an activity in a day and in order to avoid data redundancy from the figures we can understand the following facts that prove the validity of geotagged social media data 1 transportationrelated activities are bold in putuo from the neighbor district and are less than in pudong and this is reasonable because there is a major airport located in pudong 2 it can be observed that fewer people move from baoshan to the cbd in spite of pudong the reason for this is that the population and land area of baoshan are smaller and more people move from pudong 3 education activities mostly happen in yangpu 4 another interesting result is that from each neighbor district the mobility is increased in the border district compared to districts further away for example less mobility is seen from baoshan to xuhui or changning moreover another interesting result achieved by this analysis is the confirmation of different spatial patterns of people moving towards points of interest in the cbd area of shanghai our data demonstrated the tropism of travel in eight categories of the seven districts as shown in figure 18 there is a matrix for each trajectory denoted as t xy where x ∈ 123 7 categories of points of interests and y ∈ 123 8 districts t xy in each district represents the travel distance in that specific boundary of the region within a time interval that we chose namely two hours which we considered to be representative for an activity in a day and in order to avoid data redundancy the test was successful as it was able to identify the following findings 1 among all travel trajectories the matrix points out that a larger movement happened in yangpu and putuo but not in hongkou which indicates smaller movement the reason for this may be that the land area in yangpu and putuo is larger than the rest of the districts is a good illustration for the use of transportation in changning district as evidenced in the train stations or international airport in this district followed respectively by putuo and jingan 2 another interesting finding is the travel demand for entertainment activities which indicates that huangpu is a preferred choice compared to changning and hongkou which have a smaller scope t28 illustrates this point clearly where workplacerelated checkins in the hongkou district require less travel effort however it is the opposite case for the xuhui and yangpu districts with a larger txy regarding the dining category 3 the effectiveness of the sde technique is exemplified in figure 18 representing the evident direction of movement for example the direction of peoples movement in xuhui is almost northwest and movement in huangpu is nearly toward the southeast in spite of the fact that lbsn data are not precise enough to estimate the origindestination of citizens it is guaranteed from the results provided by this analysis that they are extremely helpful for urban planning and additionally the design of city infrastructure the test was successful as it was able to identify the following findings 1 among all travel trajectories the matrix points out that a larger movement happened in yangpu and putuo but not in hongkou which indicates smaller movement the reason for this may be that the land area in yangpu and putuo is larger than the rest of the districts is a good illustration for the use of transportation in changning district as evidenced in the train stations or international airport in this district followed respectively by putuo and jingan 2 another interesting finding is the travel demand for entertainment activities which indicates that huangpu is a preferred choice compared to changning and hongkou which have a smaller scope t 28 illustrates this point clearly where workplacerelated checkins in the hongkou district require less travel effort however it is the opposite case for the xuhui and yangpu districts with a larger t xy regarding the dining category 3 the effectiveness of the sde technique is exemplified in figure 18 representing the evident direction of movement for example the direction of peoples movement in xuhui is almost northwest and movement in huangpu is nearly toward the southeast in spite of the fact that lbsn data are not precise enough to estimate the origindestination of citizens it is guaranteed from the results provided by this analysis that they are extremely helpful for urban planning and additionally the design of city infrastructure discussion statistical analysis offers a robust set of techniques and tools for understanding data independently of the topic and domain in the case of mobility patterns associated with users in social media this kind of tool provides insights to understand the distribution of users how and when they interact with each other and where they move in a specific region although these techniques help to understand the way people move and interact the use of semisupervised learning algorithms provides a deeper understanding of mobility patterns and how users distribute themselves among different points of interest ultimately leading to the estimation of trending places and trajectory paths the combination of basic statistical tools and grouping algorithms allows researchers and planners to make assumptions about how users interact which after using adequate visualization tools can help to boost decisionmaking quality in smart cities additionally the adequate duration of locationbased social media data provides realworld information that supports decisionmaking in a fastgrowing environment most of the applications today analyze the textual content of information for understanding what people think and how they deliver this information to others but the analysis of spatiotemporal data is gaining momentum taking into account the benefits associated with the extraction of mobility patterns and how they can be used to increase user experience in a specific region this presents the following questions who is more active where do people tend to go how do they group among each other these are questions that can be answered with the exploratory experiments presented in this paper which highlights its relevance studying shanghai as it is one of the most developed cities reveals crucial facts that help not only city planners to make better decisions but also business developers revealing the correlation of spatiotemporal distribution helps managers to provide better services in different regions in order to reduce the congestion in a specific area and improve the quality of life for example when results reveal a specific percentage of people are moving from district a to district b for healthcare or medical services that shows people tend to get better services in district b or they are facing a lack of specific services at the origin analyzing eight different activities in seven major districts of shanghai in this research is helpful for urban planners to make precise decisions in designing a better structure for a city on the other hand identifying hot spots in the city opens a new aspect for business opportunities imagine a company wants to invest its funds to open a new branch in the city this research helps them to reduce their risk of loss compared to recent work by rizwan et el 51 in this research work we analyzed human mobility behavior different methods and algorithms had been applied on poi data and sina weibo social media data to find the cbd area of shanghai this analysis proved to be a useful source of data and validated geotagged locationbased social media data as suitable research tool for researchers by clustering similar users mobility behavior we found out a variety of citizens behavior based on their gender and distance from cbd area furthermore we investigated the reasons people tend to go to the cbd area of shanghai by creating eight groups of activities such as dining entertainment and workplaces we revealed the hidden purposes of mobility these new insights are useful not only for business developers but also for the government to improve the quality of life in developed cities analyzing weibo data in both aspects of the spatiotemporal human mobility to the cbd area of shanghai had not been focused on in the previous work as well as this users iterative checkins from home to cbd area were calculated to measure displacement matrices by haversine formula in contrast to 51 which focused only on analyzing the frequency of using lbsn based on gender differences in ten districts of shanghai we made four groups of neighboring districts and analyzed users mobility behavior and their purposes to the cbd area plus the moving trajectories in shanghai there are many benefits associated with this study but there are also some natural limitations like the availability of temporal data which in many social media channels is restricted the results are also highly dependent on the users interactivity being associated with different points of interest where a low interaction means a poor understanding of mobility patterns while a higher interaction means a better perception which can support smart city planning decisions additional limitations in this study include the users preferences relating to how often they update lifetime events users also tend to lie regarding their position and preferences as social media is not a private hub thus information could be used for malicious purposes to overcome previous limitations we explore different spatiotemporal algorithms and different preprocessing techniques for the data to refine the conclusions bearing in mind that not only the frequency of actions but also the grouping factor of data regarding the mobility of users is important the idea is to reach more accurate predictions based on automatic pattern processing rather than making inferences about variable relationships among data conclusions different statistical techniques were applied in order to extract valuable mobility patterns from the internet the obtained results highlight the viability of the proposed methodology as a way to extract spatiotemporal knowledge from users in a trending social media site considering the theoretical implications of the presented approach the following conclusions have been reached as a social media channel sina weibo provides a large amount of information that has been proven to be valuable in terms of mobility pattern discovery specifically accurate geolocated interactions increase the quality of the information discovered gender analysis over a large amount of social media interactions could be used as a starting point for uncovering finegrained trends that otherwise may be lost due to the homogeneity of data this could elucidate answers to questions such as who works more hours during the week who is more active on social media in a specific place those are questions that can be answered with this kind of analysis temporal analysis produces different statistics associated with a users activities over time helping to uncover the peak trendy hours in a region the obtained patterns also contribute to a better understanding of users activities over time and how this affects their interactions on a social media channel points of interest provide a relevant source of temporal information for finding patterns like interactions among different places and for keeping track of relevant spatiotemporal user interactions and locations 50 experimental results with dbscan here provide accurate clusters that expose important locations in users mobility filtering noisy points that apparently are important but not well connected based on distance measures this ultimately leads to patterns that can be used to discover day to day mobility in a specific region here the kde algorithm produces insightful analysis of dbscan clusters that contribute to the detection of finegrained groups based on the density of points the clusters obtained after applying both algorithms enrich the discovery of mobility patterns by detecting hot spots visited by users research on the use of statistics for understanding human mobility patterns continues to be in favor of improving obtained results keeping in mind the complexitysize of social media data ongoing and future work includes the following actions applying the proposed methodology over different social media channels considering the opportunities and constraints associated as well as the availability of open data using other wellknown statistical techniques adapting a semantical point of view for uncovering mobility patterns associated with spatiotemporal aspects of users on social media and creating a framework of toolstechniques that can be applied generically to different social media channels to produce valuable information independently of the topic and domain of the data as well as the complexity of the information supplementary materials the following are available online at author contributions conceiving the idea conducting the experiments writing the original draft and editing zeinab ebrahimpour application of statistical and other formal techniques and visualization josé luis velázquez garcía supervision and provision of study materials wanggen wan supervision project administration and proofreading ofelia cervantes and funding acquisition li hou all authors have read and agreed to the published version of the manuscript

social media data analytics is the art of extracting valuable hidden insights from vast amounts of semistructured and unstructured social media data to enable informed and insightful decisionmaking analysis of social media data has been applied for discovering patterns that may support urban planning decisions in smart cities in this paper weibo social media data are used to analyze socialgeographic human mobility in the cbd area of shanghai to track citizens behavior our main motivation is to test the validity of geolocated weibo data as a source for discovering human mobility and activity patterns in addition our goal is to identify important locations in peoples lives with the support of locationbased services the algorithms used are described and the results produced are presented using adequate visualization techniques to illustrate the detected human mobility patterns obtained by the largescale social media data in order to support smart city planning decisions the outcome of this research is helpful not only for city planners but also for business developers who hope to extend their services to citizens

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introduction at the end of 2019 the first case of covid19 was found in wuhan china within a month this new virus hit all around china by 11 march 2020 who declared the outbreak of this global pandemic the whole world was under this unwarned threat not only did people suffer physical harm from the virulence and high transmission of virus strict measures such as social distancing and prohibition of all unnecessary social interaction that were put in place also led to a severe negative impact on peoples mental health 1 existing studies provided evidence of a significant increase in the development of depressive symptoms and other mental health problems suggesting the pandemic situations were causing a lot of stress for people of all ages and genders all over the world 2 covid19 and loneliness reduced social activity and personal social contact as a consequence of physical distance restrictions and lockdowns led to higher levels of loneliness 3 whilst the feeling of being alone is normal but an excessive level of loneliness over a period can cause problems and difficulties mental health conditions such as poor sleeping quality and ptsd that met clinical criteria were all associated with feelings of loneliness during the pandemic 4 this further implies that most mental health problems have an underlying cause of being isolated and experiencing loneliness 3 loneliness is being defined as the experience of emotional and social isolation by weiss 5 it is not as obvious but loneliness could be an obstacle to people who are seeking a healthier and happier life 6 there was a global concern of that the covid19 pandemic placed everyone in a vulnerable situation people had been physically restricted and all measures had impacted the way of living all of which young people had been even more harshly affected by overwhelmed challenges 7 international students were in a particularly tough situation where they had to choose to stay by themselves in foreign lands or take the risk to get home and where the quarantine rules were very strict too this study is focused on chinese international students as chinese students make up a large proportion of worlds overseas student population according to the data from the ministry of education of china the total number of chinese nationals studying overseas in 2019 was 703500 8 moreover china has a more interdependent cultural background which means chinese people are expected to be more depressed and feel lonely in the context of the pandemic 9 as such they are a significant group to study how the pandemic has impacted on overseas students loneliness loneliness and problematic internet use in the 21 st century the rapid development of technologies has the outcome of people having more communications through the internet during the pandemic internet use had increased considerably as it was the only way for people to keep in contact with friends and distant family several studies indicate that loneliness level and internet use have a positive relationship 10 as appropriate use of internet can help people to relieve the feelings of anxiety and stress and online chat can partially improve social satisfaction and companionship 11 however this also means an extreme high level of loneliness could potentially cause excess internet use because the internet effectively helps to escape negative feelings from the real world 12 this is also sometimes referred to as an addiction to internet use or problematic internet use in addition overseas students are a group who is most likely at the risk of problematic internet use because they have already settled into the way of using internet to search for new information entertainment and connect with friends and family at home 13 therefore a hypothetical conclusion could be drawn from previous research that overseas student would have a higher level of problematic internet use especially during the pandemic alheneidi et al also suggest that loneliness and problematic internet use can be risk factors for mental health issues during covid19 14 the moderating role of emotion regulation negative emotions can be altered with welldeveloped emotion regulation strategies people who are capable of emotion selfregulatory are usually more emotionally stable because they are less likely to experience severe depressive or anxious feelings 15 as the sense of isolation is subjective the way in which people interpret the ongoing event and perceive emotions was affected by how well they could regulate their own emotions people who often feel lonely were not surprisingly found out that they did not find emotion regulation strategy helpful 16 following on from that the ability of selfregulation is associated with internet use a deficiency in emotion regulation might lead to excessive internet use as a coping strategy 17 therefore emotion regulation is also sometimes seen as a predictor of problematic internet use because of the dysfunction negative feelings such as loneliness cannot be processed and monitored in the right way 18 many researchers have studied the moderating effect of emotion regulation on loneliness and problematic internet use with other variables separately but it would be interesting to explore how does emotion regulation acts as a moderator between loneliness and problematic internet use these could have future implications study objectives 1 did the level of loneliness of overseas chinese students compare to chinese domestic students during the pandemic increase significantly 2 is there a relation between level of loneliness and the extent of problematic internet use 3 whether the strategy of emotion regulation has acted an important role of moderator between two variables method sampling method this study used opportunity sampling where an online questionnaire was adopted and sent out via various chinese social media platforms including douban and wechat they are the most popular social media among chines young adults the questionnaire was set up using wxjcom and it was in either the form of one single url andor qr code in order to avoid demanding characteristics some briefing was made for the aim of the study loneliness and emotion regulation were briefed into the investigation of psychological state problematic internet use was described as studying in behaviors additionally there were no headings for scales that have been used in the questionnaire the data were collected from the 26 th of december 2021 to the 26 th of january 2022 clear instructions and informed consent were provided measures sociodemographic characteristics sociodemographic characteristics were required this included age gender current education attainment and religions overseas chinese students were asked to provide further details of their background about studying abroad loneliness the level of loneliness was measured using the validated chinese version of the ucla loneliness scale with a cronbachs alpha coefficient of 0887 this scale was compiled by russell et al 19 a 20item scale designed to measure ones subjective feelings of loneliness arising from the gap between the desire for social interactions and the actual level of it all items are scored on a 4points likert 11 positive scored items and 9 reversed scored items 19 it had high internal consistency and the test retest relation of 073 20 problematic internet use revised chinese internet addiction scale by chen et al was used in this survey to assess the extent of problematic internet use 21 it has been widely used among chinese students it has good applicability in mainland china and its reliability and validity meet the requirement of psychometrics properties 22 this scale contains 26 items and evaluated four dimensions of addictive internet use all items are scored on a 4points likert the total score represents individual problematic internet use the higher the score the severer the problematic internet use the internal consistency reliability was 093 test retest reliability was 0830 23 emotion regulation emotion regulation questionnaire by gross john is 10item selfreport tool that used 7points likert ranging from 1 to 7 it consists of two specific emotional regulation strategies which are cognitive reappraisal and expressive suppression they are antecedentfocused strategy and responsefocused strategy respectively which are commonly used to regulate positive and negative emotions in everyday life 24 the higher score indicates more capability to regulate emotions the chinese version of erq was evaluated by wang et al both the cognitive reappraisal and expressive suppression had good internal consistency reliability 25 3 results table 2 shows a set of descriptive data the mean score of loneliness level among chinese overseas students was 4625 ± 1066 and in chinese domestic students was 4581 ± 981 indicating loneliness is a generalized feeling among students during the pandemic a total score of 44 and above is considered to be a high level of loneliness according to previous studies that were conducted before 2020 the average score of the ucla loneliness scale assessed on chinese college students were varied jia et al 26 assessed university students threetime points the average score was 3951 ± 851 4151 ± 1888 and 4151 ± 965 there was a statistical difference on loneliness level between chinese students before and after covid19 26 the mean score of internet addiction in chinese overseas students was 6413 ± 1494 which was above the theoretical score of diagnosing 27 whereas chinese domestic students had a mean score of 6206 ± 1444 that was also above the theoretical score of screening this demonstrated that the issue of problematic internet use was common among chinese young adults finally the mean score of emotion regulation in both populations was very similar overseas students had 4138 ± 820 and domestic students had 4141 ± 783 overall the difference between the two populations on all variables was not statistically different as the loneliness level is impacted by feelings of emptiness and abandonment it often involves a lack of relationship and attachments 28 further analysis on the effect of residence status on variable scores were carried out table 4 compared statistical differences in residence status and the results indicated only living on ones own and staying with friends had a significant difference there were not many differences when living with family or host family and on their own this indicated that chinese young adults require more social connections with friends rather than with family members table 5 shows correlations between variables in both groups as expected the level of loneliness and problematic internet use had a positive correlation in chinese overseas students the mean scores of ciasr and erq were negatively correlated which supports previous findings however there was no correlation between problematic internet use and loneliness level in the two populations chinese domestic students did not show a correlation between emotion regulation and problematic internet use for a better visualisation of the results please see figure 1 and figure 2 figure 3 and figure 4 demonstrate the moderating effect of emotion regulation on loneliness level and problematic internet use based on the mean scores of these two variables as both groups had a similar set of data the graphs show a similar moderating effect they both support the hypothesis of the emotion regulation strategy plays a moderating role between the level of loneliness of problematic internet use discussion the result rejected two null hypotheses and had one unexpected finding firstly the level of loneliness had increased for both chinese overseas students and international students however there was no significant difference between the two groups this implies that the pandemic affected people to a similar extent and that all chinese young adults perceived similar feelings when people were facing with restrictions the consequence of fewer social connections would indeed result in feeling isolated and abandoned furthermore loneliness level only had a significant difference when overseas students lived with friends or on their own during the pandemic which indicates that chinese young adults are becoming more independent and having less attachment with elders in comparison to previous research secondly the level of loneliness and problematic internet use were positively correlated in both groups hence this finding supports earlier studies where people prefer to use internet in order to manage their negative feelings on the internet they can meet new friends and share feelings without too much concern convenience of the use of technologies improved peoples life to a large extent as different social media help people to stay in contact with each other for example during the pandemic they could talk to each other and make video calls as such participants who had higher scores on the ucla loneliness scale also had a higher score on ciasr however we cannot ignore the negative impact of spending too much time on the internet the result also reflected that most young people are developing an addiction to internet use especially among overseas students the average score was as high as the theoretical score for diagnosing addiction to internet use once the problematic use of the internet has persisted for a long time it could have opposite effect ie internet use becomes addictive and pathological therefore interventions should be considered on the other hand there had no correlation between problematic internet use and emotion regulation this was unexpected a potential explanation can be that there were errors in the study design or this was a suggestion that internet use has become a real problem among young people the previous abnormal use of internet has become normal amount of use of internet it has increased overall moreover despite only chinese overseas students population illustrated a correlation between loneliness level and emotion regulation this finding cannot be generalized because a limitation of selfreporting is that participants may exhibit demand characteristics another limitation can be that they were answering rationally where when they are in real life situation ie in a bad mood they might not perform in the way that they think they would in conlcusion emotion regulation as a useful strategy had a moderating effect on the level of loneliness and problematic internet use the better a persons ability to regulate their emotion the less that person will feel lonely and pursue comfort through the internet this brings an important implication of the necessity of being able to regulate own emotions it improves ones mental health by using correct and healthy methods to cope with negative feelings in a timely manner this study could be improved by stating more detailed and accurate instructions so participants could perform their best the sociodemographic data can be better organized and unnecessary questions can be deleted in future research a large sample size will help with more precise findings conclusion this study obtained results from 214 responses that demonstrates the covid19 pandemic had stressed chinese students who were either studying abroad or in china the level of loneliness had increased during the pandemic due to difficulties in all aspects based on the result there was an association between loneliness level and problematic internet use but emotion regulation and loneliness were not correlated alternatively emotion regulation had a moderating effect on loneliness level and problematic internet use therefore it would be beneficial for us to master this coping strategy

the outbreak of covid19 resulted in countries all over the world publishing new strict measures which included lockdown and social distancing during this period people experienced a move away from social activities with overseas students experiencing severe psychological burdens as they were unable to return home the study was performed on chinese overseas students and chinese domestic students it assessed their level of loneliness problematic internet use and emotion regulation under the impact of the covid19 pandemic this paper explored the relationship between these variables the result suggested that as a consequence of the pandemic chinese overseas students and domestic students both suffered from a high level of loneliness the mean score for overseas chinese students was 4625 ± 1066 and for domestic students in china was 4581 ± 981 this finding indicated that the level of loneliness had a positive correlation with problematic internet use 𝑝 005 they spent more time on the internet in order to cope with negative emotions nevertheless a good emotion regulation strategy could help to overcome negative feelings in an eased way it had a moderating effect on loneliness and problematic internet use 𝑝 005

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introduction the social inequity associated with globalization underscores the need to confront social exclusion social exclusion is defined as a state or a process in which individuals or groups are denied full participation in social economic and political life and has vast negative implications for individuals quality of life despite making up more than half of the population women experience greater social exclusion and inequality this gendered exclusion is expressed in womens absence from the public sphere limited involvement in civic political life and reduced participation in the labor market these are reflected in lower income levels and greater poverty compared to men no less significant are womens subjective experiences of exclusion as manifested in decreased levels of belonging selfesteem and control as well as higher levels of stress anxiety and depression which can endanger young adults wellbeing extended young adulthood is one of the characteristics of todays global industrialized society and now covers the period from 18 to 30 or even slightly beyond this stage is characterized by the postponement of adult obligations which enables prolonged selfexploration and a search for direction in life however since socially excluded young adults mainly from lower socioeconomic strata face unique stressors in the transition to adulthood such as discrimination and higher poverty rates they have fewer opportunities for selfexploration and undergo a much more rapid transition to adulthood by shifting rapidly to participation in adult life and its associated obligations they have fewer opportunities for selfexploration and selfdefinition hence the process of identity formation is suspended or occurs in parallel to fulfilling adult roles and tasks this need to immediately embark on adult life is acerbated in terms of gender since it imposes another dimension of exclusion on already complex life circumstances which may deny women the opportunities to develop their capabilities and the freedom to plan their lives this situation adversely affects health wellbeing and thriving that extend into adulthood and can influence the next generation social workers healthcare professionals researchers and policymakers worldwide are engaged in finding ways to promote young womens successful passage to adulthood nevertheless in todays western mostly neoliberal economic context public expenditures for social security services are scarce and there is not enough social investment typical interventions targeting young adults concentrate mainly on improving labor and working conditions promoting housing solutions enhancing education and training levels subsidies and supporting health and mental health conditions nevertheless these welcome efforts have a minimal impact on inequality researchers have suggested that concentrating on practical support and providing tangible basic needs rather than directly addressing wellbeing as a social policy goal lessens the effectiveness of these interventions intersectionality as a key framework to address womens wellbeing differently the current manuscript presents a multidimensional civic engagement community participation thriving model focusing on civic engagement and community participation to promote the thriving of socially excluded young adult women the model draws on major critical postfeminist theories which implement the notion of intersectionality as a key framework for designing interventions for socially excluded populations intersectionality refers to the complex process and interactions between multiple identity dimensions of ethnicity class gender and sexuality and their manifestations in experiences of marginalization social disadvantage and poorer health outcomes the concept of intersectionality aligns with theories of critical realism in rejecting the quest for a universal pattern of inequalities instead this framework seeks to unpack inequalities in social processes and uncover the subjective meaning of living in an intersectional position originally black feminist scholars advanced intersectionality theory to account for multiple forms of subordination in the legal and political domains nevertheless recently intersectionality has gained increasing prominence in health studies that have examined how the health and wellbeing of various groups are impacted by structural oppression or marginalization according to the intersectionality approach multiple forms of oppression experienced by a single person have a cumulative effect that directly influences the individuals internal sense of self and wellbeing therefore to enhance wellbeing the interlocking nature of multiple forms of oppression must be disentangled so that the ways power dynamics at the macrolevel of social systems and institutions interact with interpersonal relationships and subjective experience can be identified thriving as a core concept although intersectionality theory emphasizes the voices of people experiencing interlocking disadvantages it does not restrict its focus to the experiences of suffering and oppression rather it calls for identifying resilience and resources available in an intersectional social location nevertheless since a main developmental goals for disadvantaged young adult women is broadening future possibilities returning to baseline while avoiding adverse outcomes does not capture their full potential dominant theories in social welfare humanities and positive psychology have all advanced the concept of thriving to characterize better individuals wellbeing thriving is defined as flourishing prospering and progressing toward or realizing a goal despite the circumstances thriving views human development as a process and describes the aspiration for a very high living level and fulfillment of human potential different researchers have divided the concept of thriving into various domains the three prime dimensions are feelings of happiness enjoyment comfort contentment and the absence of distress a sense of purpose and meaning in life selfactualization progress towards meaningful life goals selfefficacy agency and control and engaging in deep close healthy relationships the model built on the key concepts of intersectionality and thriving the current article describes a multifaceted developmental trajectory model designed to promote the thriving of socially excluded young adult women by participating in critical civic engagement program in a setting of a community of peers the model is based on the premise that civic engagement in a community setting can directly augment these womens thriving by promoting a sense of meaning and purpose in life in addition participating in a community was hypothesized to directly encourage marginalized womens social thriving by providing them with the opportunity to establish deep and meaningful relationships and social networks as well as fostering their hedonic thriving by instilling positive emotions and life satisfaction this model thus innovates by charting the indirect development towards thriving through the mediation of selfexploration which can lead to the fulfillment of all three thriving domains and promote these womens identity formation specifically social thriving contributes to identity formation whereas eudaimonic thriving and identity formation mutually reinforce one another although the assumption that civic engagement promotes wellbeing and identity formation has often been explored few studies have examined the mechanisms through which civic engagement enhances wellbeing only a small number have provided a complete framework to describe the ways civic engagement promotes wellbeing and advances the eudemonic hedonic and social components of thriving when characterizing the contribution of civic engagement in most cases the literature has discussed the contribution of servicelearning programs to undergraduate students even when lessrepresented female students have been the focus these studies have been conducted in the context of campuscommunity partnerships for instance markovich et al examined campuscommunity partnerships operating in israel while exploring the potential of these partnerships to facilitate transformative change in conflict zones although their book takes a feminist perspective and deals with how institutional hegemonic academic dynamics shape students identity the authors mainly concentrate on how campuscommunity partnerships expose these dynamics to promote social change and advance human rights in conflict areas thus identity exploration as a primary liberating vehicle to promote thriving is not the central theme civic engagement as a driver of thriving civic engagement refers to how individual and collective actions aimed at addressing issues of public concern are undertaken to improve conditions for others andor help shape a communitys future engagement of this type can lead to a sense of connection interrelatedness and commitment to the community at large civic engagement includes any step intended to enhance the quality of life it can take many forms from individual volunteering to organizational involvement and from addressing a specific social issue and promoting social change to voting these acts can be regular or episodic and constitute one of the fundamentals of a democratic society that emphasizes active citizenship data indicate that womens civic engagement is often situated in the private sphere within their homes and neighborhoods where they can express their voice in a secure atmosphere before turning to larger civilian spheres overall research findings are consistent with the notion that civic engagement can be highly beneficial having a positive cumulative effect on individuals physical and mental health life satisfaction and thriving for example a crosssectional empirical study on students reported a strong relationship between civic engagement and wellbeing mediated by service selfefficacy and meaning in life a review and metaanalysis demonstrated that volunteering positively affected depression life satisfaction and wellbeing further empirical support for these findings emerges from a crosssectional survey showing that in comparison to nonvolunteering formal volunteering once a week was associated with twice the likelihood of thriving similarly studies have repeatedly shown that civic frontiers in psychology 04 frontiersinorg engagement is a significant driver of young adults thriving generating selfefficacy and agency and meaning in life nonetheless socially excluded young adults engage less than young people from higher socioeconomic classes partly because such activities are too burdening for those who are already burdened however fenn comprehensive literature review suggests that an informed tailoredtoneed civic engagement activity can facilitate participation and bolster thriving studies have shown that civic engagement can compensate for a lack of resources and development opportunities through exploration and helping others which enables disadvantaged young adults to experience personal change specifically in terms of resilience identity and social capital civic engagement as a generator of meaning in life satisfaction in life and positive emotions studies on highly diverse samples implementing various forms of data collection suggest that significant sources of meaning in life can be derived from personal relationships achievement success and altruism specifically engagement at the macrolevel while addressing values needs goals and caring for others enables individuals to be involved in a eudaimonic activity that targets issues beyond the ego and mundane concerns hence connecting to something more significant than the self is critical to advancing individuals wellbeing by grappling with challenges and unexpected situations in new surroundings individuals are called upon to show initiative and creativity and acquire new communication and leadership skills these promote their sense of selfcompetence and lead to the realization of personal potential this suggests that civic engagement facilitates a sense of meaning and purpose in life which provides individuals with a crucial way to allocate their resources toward meaningful achievements that give a sense of satisfaction and happiness the idea that engaging in eudaimonic actions such as civic engagement can facilitate positive emotions is also based on aristotelian philosophy as manifested in sheldon eudaimonic activity model we suggest that for women who are not regularly exposed to such experiences in particular civic engagement can be highly beneficial by fueling them with positive emotions and a sense of enjoyment this can have a cumulative effect which relieves their draining alienating and muted reality and can promote thriving both directly and indirectly the civic engagement community participation thriving model birger sagiv et al 103389fpsyg2022955777 frontiers in psychology 05 frontiersinorg community participation as a generator of social and hedonic thriving community participation is a broad and complex term describing interactions and collaborations among individuals with similar identities goals and interests through an ongoing process of participation the identity of the participants and the community itself is continuously created supporting the development of social capital social capital is a term with many definitions relating to the amount and strengths of social connections stemming from family support peer networks and community stability it is customary to divide social capital into bridging and bonding representing different levels of connectedness and the quality and or quantity of social relations both of which are increased through community participation bridging social capital refers to establishing relationships between different groups of people within and outside the community characterized by weaker ties and often referred to as operational or general community participation these relationships can enable socially excluded young adults to extend their social networks engage with meaningful organizations in their environments and widen their mobilization opportunities which constitute an important way to promote their future options and status bonding social capital refers to strong relationships between individuals within a homogeneous group the development of close and meaningful relationships promoted by participating in a community aligns with womens inclination to group in what is classically termed sisterhood communities to promote womens rights and involvement in the sociopolitical arena these communities characterized by trust support coalitions collaborations and effective communication allow women to participate in decisionmaking about their future and improve their lives in addition these communities play a protective psychological role by reducing stress lessening depression improving social wellbeing and at times peoples lifetimes increasing community participation is an essential component of integration in a democratic society which helps fight poverty and social exclusion thus for socially excluded young adults participating in a community that combines positive and meaningful relationships holds numerous benefits these include strengthening their significance to others while augmenting a sense of worth belonging and connectedness it also compensates for the lack of social resources crucial to young adulthood serves to establish networks and can help overcome experiences of adversity it thus enables the development of resiliency positive emotions and better health this is especially true for women who use social networks as a powerful resource for promoting social resistance and social rights in our model participating in the community serves as the platform for civic engagement and a vehicle to catalyze womens social and hedonic thriving identity exploration and intersectionality selfreflection as a generator for thriving and identity formation civic engagement and participation in the community can also shape the process of selfexploration and identity formation the cornerstones of our model identity formation is often divided into exploration and commitment exploration is defined as actively engaging in targeted activities and searching for alternatives while trying to answer the question of who am i commitment refers to making decisions about these alternatives while defining myself identity formation is a core developmental process that begins in adolescence and continues into young adulthood in which different dimensions of identity evolve towards greater maturity forming a more stable identity in different content domains it is characterized by individuals increased reflection on their certainty about their commitments findings have indicated that individuals who have made identity commitments ideally through a process of exploration have fewer mental health problems engage in fewer healthrisk behaviors have fewer mental health concerns and report higher levels of psychological wellbeing and meaning in life our model suggests that civic engagement as a eudaimonic act within a community setting can catalyze identity formation through a reflection on the intersection of the components of identity and identity exploration simultaneously specifically it suggests that civic engagement can be experienced as a selfformative and maturational experience that can shape womens identity and selfknowledge and serves as a springboard for shaping life goals and plans through civic engagement women are called upon to explore new abilities and skills and fields of opportunities explore career choices examine new roles and build a network of connections in this respect civic engagement may serve as a vehicle for acquiring social thriving reflected in social capital which is especially important for individuals from frontiers in psychology 06 frontiersinorg socially excluded minority groups with fewer opportunities to be actively involved in identity exploration furthermore interacting with people who differ in terms of age social strata and ethnicity from people that individuals encounter regularly generates questions regarding sense of self and may encourage women to explore their strengths and weaknesses hence through their civic engagement women can actively search for a more vigorous sophisticated and defined sense of subjectivity as to who they are and how they fit into their social world establishing a more robust subjectivity may also be enhanced through interaction with other women in the community which can serve as a hall of mirrors reflecting womens abilities assets and difficulties as a part of the change process reflection on ones civic engagement forms the common thread of the model because it emphasizes the importance of cognizing ones eudaimonic activities both personally and collectively once women reflect on their upbringing intersectional identities assumptions values and restrictive conditions in which their civic engagement is enacted critical social consciousness begins to form this awareness helps them further analyze the world in which they live and promote their selfdetermination despite the systemic oppression they become more aware of by applying an intersectional lens disadvantaged women often recast their trauma as a motivation for taking on an active role and choosing the field of civic engagement critical feminist thinking and intersectional theory both emphasize the need for socially excluded women to uncover how the components of their identity are differentially influenced and affected by social status class and ethnicity within a specific historical context in this vein research indicates that when civic engagement is viewed as a revolutionary act of the self in response to sociopolitical inequality it can integrate into ones identity in the form of resistance thus forming an adaptive coping strategy that can promote eudaimonic thriving more generally researchers have suggested that interventions which involve civic engagement as a strategy to promote thriving are beneficial especially when they implement social justicebased or critical civic engagement point of view thus womens selfexploration that concentrates on the components of context ideology social structures and power relations and extends beyond the practical aspects of acquiring skills and knowledge is likely to enable the construction of meaningful different identity components to serve as a broad platform for their selfrealization and development examples in israel several projects and programs have been designed to enhance young adults eudaimonic social and hedonic thriving through civic engagement that promotes identity exploration in light of intersectionality these include the civic service of arab young adult women which according to yanayventura et al offers young arab women the opportunity to crystalize their personal and citizenship identity this takes place by exploring aspects of discrimination and marginalization that shape their identity and acquiring new skills and economic independence thus bypassing the glass ceiling the authors noted the concept of cultural capital and described how the participants unpacked various aspects of exclusion and discrimination internalized in their identity these benefits are especially interesting given the ambivalent public attitude and opposition to participation in arab communities goldner and golan describes the israel scholarship education foundation program this program operates civicengagement socialeducational projects in which students from disadvantaged backgrounds regularly meet marginalized communities for two to 4 hours per week in return for a scholarship the project aligns with the foundations vision of reducing social gaps through higher education the findings pointed to the significance of volunteers reflections on culture ethnicity and power distributions which validated their cultural heritage and integrated intersectional aspects of their identity below we focus on the young women in the lead social activism in young adult womens communities program under the auspices of the fund for demonstration projects of the israel national insurance institute and the gandyr foundation during this program various organizations established 20 communities for socially excluded young adult women across israel these womens communities are characterized by multiple marginalization such as belonging to an ethnic minority group residing in lowincome peripheral towns and lacking family support in some cases the women had a history of child abuse neglect or personal trauma all amplified because of their gender in most cases the women were recruited through welfare bureaus the project aimed to encourage civic engagement as an innovative approach to promoting womens wellbeing the communities consisted of 510 young women who participated in weekly twohour meetings in which designated coordinators introduced the women to issues such as civic engagement skills socialpolitical awareness social justice and gender participants were invited to be involved in building the community and initiate civic engagement that addresses social issues derived from their life stories and circumstances women were also invited to consciously reflect on matters of intersectional identity social justice and gender throughout the program in group discussions guided by the communities coordinators the example below is taken from four indepth semistructured interviews with a 23yearold arab israeli woman who participated in one of these communities for 3 years research assistants conducted the interviews in arabic and later translated them into hebrew the interview consisted of questions about the communitys progress these included what expectations did you have from participating in the project if someone were to ask you to stop for a moment and look at your life to this day how would you describe it can you describe how participating in the project has affected your life do you have plans for future jobs education leisure family and relationships asil is a 23yearold arab israeli woman living in a large muslimdominated city in the north of israel she was asked to recollect her motivations for joining a civic engagement community her response revealed a life full of hardship and despair leading her to hope and wish for change i have gone through many periods of hardships in my life and i am still going through them sometimes there are moments of despair when you are sure nothing will work out and you are exhausted but these dont last they are just bits of the time afterward you return to the struggle nonetheless this wish for change has little hope of coming to fruition as shown by her sense of ambivalence and hesitation at first i hesitated my mother said you will not lose anything try so i joined the community here she nevertheless made it clear that something was profoundly missing by saying after graduation i had a lot of free time i felt like i was not really me i wanted a change in life in my personality a break from the routine to breathe a little just to go out to feel independent and see beyond routine later asil talked about the importance of being part of a supportive community of women gaining confidence and exploring her capabilities she repeatedly used the terms voice and voicing the self as constituting significant steps in acquiring knowledge about the self and building her identity she recalled i remember at first i was timid i could not express myself later on she dared to express herself especially in less conventional fields in her milieu im glad i joined i found a place to express my voice to speak freely about topics that are not usually discussed it was very empowering that the group is for girls and you can both give and receive be a voice for those who do not have enough voice to speak and express themselves she continued by defining civic engagement as …the possibility to give to each person every little thing that can help support and promote thus linking the processes of civic engagement with personal and social change in fact she saw these three processes as almost identical it first and foremost starts from the inside it does not matter for whom or for what the main thing is that you stand up to support yourself take care of yourself and thus others as well i come here on my day off without many hours of sleep so yes i am an activist… i am a little different each time i come here sometimes i am calm sometimes nervous sometimes talking sometimes quiet etc and i know that i am accepted as i am and acceptance is mutual of course that in itself is activism accepting the other allows for free authentic and the truest expression of the self in addition she described her identity development associated with eudemonic thriving and the joy associated with this development i personally have developed a lot… i feel growth… i am very happy… creating change talking about rights about women bringing things to light and not hiding them as is customary in my culture it is exciting to understand that my participation is important that i can contribute another voice another opinion another question… another idea of being part of something in terms of change and selfexploration asil described the persistent gap between her aspirations for identity exploration and her limited possibilities and choices in her view this gap began when she graduated from high school and started thinking about what i would like to do and not just what i need to do even though i do not see why there are things that prevent me from thinking and dealing with these thoughts and questions but when i want to act sometimes i have to convince those around me and negotiate with my immediate environment these limitations relate to her social positioning which she perceives through selfreflection in the light of intersectionality asil gained an understanding of this gap which is related to her life circumstances and society in general and this has allowed her to broaden her perspective make different interpretations and engage in a range of actions as she courageously described the community has been by my side through a process of selfawareness and connection to the self today i know asil better more than ever i am connected to who i am and believe in everything i am i will give you an example one day i had to go to the city and on the way i saw a man beating a woman i was stressed i cried but nevertheless i had the courage to call the police and report it i felt really proud that i have the ability to defend to express to speak not to be silent i did not use to be like that i did not have that courage the community is a big part of all the inner changes i have gone through at the end of the final interview asil summarized her 3 years of participation her statements illustrate how the components of the model are combined and interconnected she related to the importance of community in instilling feelings of connectedness and serving as a safe place for selfexploration in a secure atmosphere which allows her to contemplate and shape a different way of thinking she repeatedly used the word change to describe another example is hadil a 20yearold arab israeli woman living in a mediumsized village in the north of israel in response to a question about her interest in wanting to join the community to be involved in civic engagement she talked about the importance of a supportive womens community she described wanting to create a secure space for her and others to promote change through civic engagement referring to the internalization of discrimination and social control by the women themselves she said i am in favor of women changing working for peace… first and foremost among the women themselves we are very oppressive of each other when we criticize and censor each other out of social conventions that we ourselves reinforce women are supposed to have each others backs this is where activism begins and this is where change really begins in a later interview she talked about her growing feelings of connectedness and belonging in the community fostered by the women and the communitys coordinator she described how these feelings catalyzed her motivation for active civic engagement which led to meaning and purpose in life hadil also provided a sense of the indirect connection between civic engagement and community participation with identity exploration i feel and see that many things have changed since joining the community lets start with the fact that there is support the girls support me and my aspirations and i support them it is very encouraging beyond that i am more active i go out into the community to act i started volunteering at school i participate in community projects i have power i feel i have meaning and i have a purpose… im important and the fact that i can give makes me feel even more powerful this is what encouraged me to want to get more education expand my horizons and continue to be active for others and for myself it makes a sense of vitality and hope hadil elaborates how being a part of a group of women who share experiences ideas and actions regarding womens inequality led her to reflect on her own life in the light of intersectionality and experience selfchange she described taking a more critical point of view on the condition of women in her community being more empathic caring more for others she describes many good feelings which are related to being a part of something and being active towards something novel within her reach the activity enabled me to see a truer picture of women in society and the oppression of women the group activity made me look at people more empathetically while thinking of more options before i joined the community i was not interested in what was happening in the village or the conflicts we were facing today i feel more caring and interested in participating in the change today i feel it is my duty to understand know and take an active role in repairing and improving before joining the community i saw myself as an ordinary girl living for ordinary needs and normal roles today i see myself as more vital i do not just exist to exist i exist for action to be part of and for a goal summary and implications our theoretical model suggests a trajectory of subjective thriving through participating in community civic engagement via the mechanism of selfexploration and intersectionality although this kind of civic engagement differs from conventional civic engagement in young adults that evolves spontaneously policymakers thirdsector organizations institutions involved in service learning and other welfare and health practitioners working with underprivileged populations can draw on this model to promote thriving among socially excluded women and other populations this could involve developing white papers and plans for program interventions that decisionmakers can use to allocate budgets and resources to establish civic engagement communities for socially excluded populations for civic engagement to be perceived as meaningful attention should be paid to educating young women on how their personal lives can be translated into community goals and concerns one way to do this is for social workers and field practitioners to guide and support the women in transforming their broad social goals into a series of small but meaningful acts of civic engagement to avoid despair and maintain motivation time and effort should be devoted to teaching women civic engagement skills and providing them with a solid background efforts should be made during community meetings to develop political awareness and critical thinking that can enable women to reflect on their identity in terms of the premises of social justice engaging in critical civic engagement that fights institutionally structured power dynamics which curtail womens frontiers in psychology 09 frontiersinorg rights may encourage young women to express their silenced voices and reconsider their intersectional experiences they can then actively address social concerns from the agents perspective rather than that of the victim while considering the issues of equality and patriarchy which can restore their sense of agency and foster a liberating antioppressive standpoint of engagement social workers and healthcare professionals should be aware that when prolonged civic engagement addresses personal and social needs and is analyzed in terms of gender and identity it can become an internalized element in womens identity that can promote resiliency and thriving social work curricula would benefit from incorporating thrivinginformed interventions that go beyond subsidies better housing scaffolding education and professional training and should offer courses centered on paradigms targeting wellbeing and positive development trajectories this transformation would help disadvantaged populations more fully develop their potential in their communities despite structural inequality and intersectional discrimination data availability statement the original contributions presented in the study are included in the articlesupplementary material further inquiries can be directed to the corresponding author publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

social policies to promote socially excluded young adult women generally concentrate on education employment and residence but tend to neglect thriving the current article puts forward a civic engagement community participation thriving model cecptm that views thriving as a social policy goal in and of itself it posits that civic engagement beyond its contribution to social justice serves as a vehicle for thriving through selfexploration and identity formation both are considered key components of successful maturation and thriving nonetheless civic engagement and selfexploration tend not to be nurtured in socially excluded young adult women a unique group experiencing intersecting discrimination the model shows how active civic engagement in the context of a community of peers contributes to developing a sense of belonging and connectedness and promotes new selfreflection identity formation and agency capabilities when situated within the context of intersectionality these encourage the development of critical consciousness and new understandings of who i am and how i fit into the social world in which we live these can provide a sense of meaning contribute to identity formation and promote the thriving of the self and the community several examples illustrate the model

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introduction religious teachings have a prominent place in peoples understanding of hivaids in africa and therefore an important factor in the discourse on hivaids in the continent nevertheless the relationship between religion and hiv is not very clear for instance a study in zambia among teenagers reported that affiliation with religious groups that excommunicate members for engaging in premarital sex are more likely to delay the onset of sexual intercourse among young women but less likely to promote the use of condoms during first sex another study in malawi found that adolescents who attend religious services frequently are less likely to be sexually active than those who do not and those who attend congregations in which aids is discussed frequently are more likely to be virgins thus there appears to be some kind of doubleedged role of religion in the regulation of sexual behaviours with implications for hiv and aids prevention in africa that needs further examination ghana is constitutionally a secular country but by behaviour ghanaians have been described as radically religious there are three predominant strands of religious tradition in ghana christianity pulls 65 islam pulls 15 and the 20 are for traditional religions and some other forms of eastern religions such as hinduism buddhism as a powerful social force religion has impacted on the cultural scene so much so that it has become a major cultural manifestation in thought and action affecting the entire public sphere of the country one way religion exerts its social force in the country is that it provides a moral framework for sexual socialization and anecdotal evidence exists to confirm that religious themes feature prominently in adolescents conversation on sex and sexuality studies therefore have begun investigating the religionhivaids connection among various groups of people in the country one such study was conducted by takyi with the purpose of exploring whether a womans knowledge of hivaids is associated with her religious affiliation and whether such affiliation facilitates aids preventive attitudes the findings showed that religious affiliation increases womens knowledge and awareness of hivaids no association was established between religious affiliation and changes in specific protective behaviour such as the use of condoms in another more recent work by gyimah et al the sexual risktaking behaviours of religiously affiliated ghanaian men were studied their findings showed that at the bivariate level christian men were more likely to engage in high sexual risk behaviours than their muslim and traditional counterparts to the best of our knowledge not much has been done on the evidence concerning how religious factors could become protective or risk for adolescents sexual behaviour in ghana adolescents form nearly 50 of the entire population of ghana as in other countries economic and sociocultural pressures promote unsafe sexual practices among adolescents especially those living in the poorest communities in the country ghana statistical service report places the median age for first sex for adolescents at 175 years and that 38 of girls and 19 of boys between 15 and 19 years of age are sexually active a fertility survey in ghana reported that although there were high levels of contraception usage most adolescents were still very sexually active the estimated national hiv prevalence among the youth ranges from 11 among 1519yearolds to 17 among 1524yearolds these rates put together indicate prevalence rate is high among people within 1524 years of age and 28 is higher than the national average of 17 this necessitates the need for increased research into possible sociocultural factors that could have influence on the reported rates methods the approach of this study was qualitative qualitative studies are often used to explore a phenomenon that has not been previously well delineated the study relied on a qualitative data initially generated from a longitudinal cohort study of adolescents and their parents residing in two communities in southeastern ghana these communities are characterized by dramatic variations in localized hiv prevalence allowing us to assess how epidemiological circumstances impinge upon adolescent sexual behaviour in using the qualitative approach the study specifically employed focus group discussions to investigate parental attitudes towards adolescent sexual behaviour and how these differ for boys and girls the common strategies used by parents and the community to address adolescent sexual behaviour and the challenges and successes they face in doing so some of the items on the focus group discussion guide included the following who should educate the teenage boy or girl on issues relating to sex whose duty is it in particular to check the behaviour or conduct of adolescents between 13 and 18 years in this town what should parents do if they realize that their underaged children are engage in sex in reality are parents talking to their children about sex and if they do how do they do it in this town the fdg was conducted one with mothers of adolescents and one with fathers of adolescents in each of these two communities study settings somanya the residents of the manya krobo and yilo krobo districts of eastern region have experienced a particularly severe hiv epidemic this is due in part to the circular migration of young women from this area to abidjan côte diviore where many participate in commercial sex worka phenomenon that dates to the displacement of populations by the creation of lake volta during the 1960s the severity of this localized epidemic is reflected in sentinel surveillance data the antenatal clinic in somanya manya krobo district has consistently recorded the highest levels of hiv prevalence among all 40 of ghanas sentinel surveillance sites in 2006 prevalence at somanya was 84 compared to the next highest prevalence of 56 and the national average of 32 epidemiological studies in the area also demonstrate very high levels of hiv prevalence chang and colleagues found that 23 of male and 17 of female outpatients seen at the somanya hospital in 2000 were hivpositive while another team documented an hiv prevalence level of 185 among women attending antenatal clinics in somanya and nearby atua in 1999 somanya is a regional trading centre about 30 km south of the akosombo dam with a population of 13508 according to ghanas 2000 population and housing census the main road from accra to akosombo passes through it and smaller roads branch out in several directions to rural villages and farmland adidome it is located in the north tongu district just 25 km to the northeast the town of juapong in the north tongu district of volta region and has much in common with somanya it is a regional trading centre located on a major road surrounded by rural villages and farmland along smaller roads in several directions according to ghanas 2000 population and housing census its population is 13103 in contrast to somanya however this area remains largely untouched by hiv among the 805 women attending the antenatal clinic at the north tongu sentinel surveillance site in 2005 and 2006 none tested positive for hiv no other site in ghana recorded a prevalence estimate this low during that period access to communitiesauthorization was sought from local authorities mainly chiefs elders and elected officials having explained the purpose of the study to officials in the two communities the study began with a community event in both localities during these durbars traditional and modern authorities announced the purpose of the study in line with ethical principles community members were not coerced and induced into participating in the study they were told that they could opt out in the process if they found the study uncomfortable during each phase of the study communitywide events were held where community members received refreshments this was to provide the opportunity to interact with members of the research team as well as provide positive publicity for the study and serve as a method of communitylevel compensation participantsin order to ensure gender equity both female and male participants from the two communities took part in the study in effect participants in the study included mothers of adolescent children female caregivers of adolescents fathers of adolescents and male caregivers of adolescents this was also to ensure that information received takes into account a gendered perspective for purposes of convenience and anonymity participants who showed interest in the study were asked to contact the researchers to be a part of the focus group that was made up of 68 members for each group analysisthematic analysis was used to generate themes this method of analysis is used to identify analyse and report patterns within data as well as interpreting various aspects of the research topic one of the benefits of thematic analysis is its flexibility and can be applied across a range of theoretical and epistemological approaches the analysis started by looking for patterns of meaning and issues of potential interest in the data and organizing them into meaningful coding schemes or groups this was followed by sorting the different codes into potential themes a theme was not necessarily dependent on quantifiable measures but in terms of whether it captures something important in relation to the overall research question themes were finally refined defined logical connections established between them and interpreted three themes emerged as a result they were as follows the context regulatory mechanisms for moral behaviours religion an alternative moral system regulating sexual behaviour and conceived differentials in the utility of religion results the context regulatory mechanisms for moral behaviours this theme examines the contexts of the two communities with regards to the existing cultural practices beliefs ideals and socialization principles which guide moral behaviours two major regulatory mechanisms were identified in these communities one was the dipo rite in somanya and the other was gendered and communal socialization principles in adidome dipo is a long standing initiation rite for female children between 14 and 20 years practiced among the krobo a subgroup of the gaadangbe ethnic grouping in ghana not until the rite has been performed young girls have not been socially licensed to be courted by prospective men into marriage and thus among other things was intentioned to control the moral and ethical behaviours of the girl child those who failed to go through the rite in the past were banished from their communities as they perhaps were conceived as transgressors of social law participants expressed a moral system that was provided by dipo and how it guided discrete sexual behaviours in the past thus so when a child is growing then parents cover her up for 25 years then they say she has performed the rite in those days if you dont do the dipo and you get pregnant they will sack you so there was fear and the children also…their bodies therefore become matured for marriage and child birth therefore when they become pregnant there is no problem explicit in this statement is that a context that was proscriptive of indiscrete sexual behaviour was in place historically and that it exercised strong regulatory influence over childrens sexual behaviour any sexual behaviour prior to the dipo rite was counter to this moral system furthermore there is admission of the perceived viability of this moral system through the dipo rite this is found in the indication that people feared and thus delayed sexual activity until adulthood when they are ready for marriage thus the deterrence ideology of the dipo rite is further made to validate the perceived viability of the existing moral system this deterrence ideology was not viewed to be felt by female children alone but also boys this is manifested in the statement by a woman during a focus group discussion because the boys are trained and know the consequences of impregnating a girl who has not performed the dipo rite they will not go chasing a girl who has not been initiated although boys do not go through the dipo rite the prohibitions and consequential ramifications were strong enough to deter them thus in a nutshell parents from somanya viewed the dipo as providing a viable moral system of sexual conduct among adolescents among parents of adidome reference was made to socialization as providing a moral system guiding adolescents sexual behaviour socialization is the process in which people learn the attitudes values and behaviours considered appropriate for members of a particular culture the parents in adidome indicated that within their community there is a form of gendered socialization this is a form of socialization where children are exposed to expected sex roles from parent of the same sex thus fathers trained boys and mothers trained girls this gendered socialization was viewed as providing a moral system that regulated adolescents sexual behaviour this is expressed in the following voices by our ewe traditions or culture a boy should be with the father and learn his fathers trade so that if in future if the father is dead or become incapacitated he can take his place and hold the family together so with us in the past before a young man marries he should know how to cast the net the professions may differ elsewhere by this the child should be at least 25 years old and be employed somewhat before they marry good here while the mother was training up the girl child the father was also training up the son so that in the future when a woman is married for him he will know how to take care of his household in summary both parents in somanya and adidome admitted that there is an existing cultural moral reference point against which all conducts are assessed these standards provided regulatory influence over all aspects of adolescents behaviours including sexuality religion an alternative regulative moral system in this theme we examine how parents viewed the role of judeochristian religious values in the regulation of moral conduct of adolescent children all the parents from both communities indicated that religion as a moral system existed sidebyside with other traditional forms of moral regulation the quote below explains communal socialization existing sidebyside with religious instructions from pastors from some time in the past till today there have been plans to check our young ones there is a general responsibility on all to check and control the children we correct one anothers child the pastors and the church talk to the youth about their future in their sermon the moral system religion produces appeared strong such that parents saw it as an alternative to the traditional systems when they could not exert any meaningful influence on regulating their adolescent sexual behaviour they switched to religion for help as a supplement when parents fail in controlling the sexual behaviour of their wards the religious bodies like the churches can also be of help the switch towards religion as a regulatory moral mechanism over adolescents sexual behaviour is validated on the perceived benefits from this moral system parents perceived religion as playing two major positive roles in regulating the adolescents sexual behaviours the first was the inhibitive role this is the view that religious values deter children from certain immoral acts for instance in our time if you dont go to church on sunday the next day when you go to school what is done to you is not small these days because of that lack of fear even church they dont attend gods word is not in them anymore so this is our problem in this quote this parent juxtaposes generations the generation of his time lived in a moral space where religious control was very strong to the extent that absenting oneself from religious meetings constituted a great offence the reference to lack of fear in the present youth is an admission of the fact that adolescents in contemporary times seemed to have left off the hook of religious moral control this participant seems to endorse the idea that if modern children stay within religious boundary it will inhibit unacceptable behaviour secondly religion was perceived to play a facilitative role in this role religious values principles ideals and perhaps beliefs instruct adolescents to make good choices as indicated in the following voice some christian parents who are not happy about their childs sexual behaviour report them to the church elders to talk to the child this role is best served by religious leaders who virtually become counsellors for adolescents the talk therapy that is provided is reflective of religion guiding the choices of adolescents sexual behaviours ensuring that adolescents fully participate in religious meetings was thus a responsibility of parents it was thought of as a process of guaranteeing that children will achieve excellence in all matters of moral behaviours as they might imbibe lessons that could foster proper conduct what i have realized is that most parents ensure that their children go to church so they can learn good things from church conceived differentials in the utility of religion although certain positive impact of judaeochristian religious beliefs practices and values have been acknowledged by parents from these two communities as relevant in regulating adolescents sexual behaviours parents differed in the way they perceived the utility of religion in the regulation of adolescents sexual behaviours starting from parents from somanya they asserted that judeochristian beliefs and practices to a large extent also do disparage the existing dipo puberty rite i also observed that some churches or religious bodies that have come around are also spoiling the children like in our custom here there is an age a child has to attain before marriage these days some of the religious groups or churches do not support the dipo and we have also imbibed their teachings like that and the children are spoiling religious beliefs espoused by churches find dipo rite contrary to the bible as a result they do not encourage children to participate in the rite this parent indicates that religion is transforming the moral fibre of their children indirectly by perhaps indoctrinating them about this traditional rite the grip of the custom on children and beliefs about its usefulness is debunked and replaced by judeochristian beliefs as long as the motivation to participate in this rite is weakened this parent interprets that as spoiling thechildren perhaps one way parents viewed religious indoctrination of the dipo rite was through fetishism thus making it appear demonic and destructive some are doing it but due to christianity the pastors dont want us to do it because they dont understand they think its fetish but its not it is a puberty rite which young people observe but they dont support it we are teaching or explaining it to them but they still say no within contemporary ghanaian sociocultural space whatever is believed to be fetish is equally considered to carry a negative connotation because judeochristian teachings seemed to have christianized the entire public sphere according to this parent such views of the dipo rite is inadequate but attempts to straighten these views are unsuccessful implicitly this parent is apprehensive over the possible consequential stigma that will be attached to the rite judeochristian religion is thus viewed as damaging the traditional moral structure system as most parents seemed to have accepted this fetish ideology about the dipo rite and do prevent their children from being initiated today we say we are pastors and we have spoilt everything and spoilt the children because we say it is fetish but its not fetish so when a child is growing then parent cover her up for 25 years then they say she has performed the rites the views of parents from adidome were different we did not find any negative reference being made about judeochristian beliefs and practices in how they regulated adolescent sexual behaviours in this community compared to somanya further analysis showed that two major means by which parents from adidome community inculcated social norms into their children could offer some explanations firstly there seem to be a deep sense of communal socialization in adidome this implies that they viewed the raising of children as a societal responsibility as indicated in the following voices from some time in the past till today there have been plans to check our young ones there is a general responsibility on all to check and control the children we correct one anothers childchildren another father corroborates this thus here in north tongu the upbringing of children is a collective responsibility of all parents parents report children who do bad things to the parents of those children explicit in these views is partnership which adopts collaborative efforts in socializing children beneath this partnership is a certain sense of unconditional positive regard for another persons child by this parents accept every child as their own and that provides the basis for disciplining another persons child in these areas every parent disciplines a child when they go wrong there is nothing like he is not my son or daughter so i cannot punish her practically a mother demonstrates such communal socialization in the way she handles a child who breaks into another persons room i for instance saw someone entering somebodys room through the window and i called the child took the child home and advised the child that what he is doing is bad in general communal socialization in adidome exercises parenting as not the exclusive reserve of biology but also societal secondly adidome community seemed to endorse a certain level of proscriptive morality this is an inhibitionbased condemnatory and strict oriented morality which tends to blame people and generally focuses on what people should not do a father espouses this thus fornication is very much disgusted and is a shame in our land i will also add that parents here do not allow their children too much freedom to go to entertainment centres such as the dance halls such inhibitionbased morality is practically expressed in this town by a committee that is mandated to enforce it as explained by a father thus we have some committee in this town and they watch over the town in the night so if they get hold of a young man or young woman in the night they beat them up so they will stop doing bad things in this town at the core of communal socialization and proscriptive morality practices as found in adidome from the voices of the parents is to train adolescents to conform to social expectations this goal could equally be executed by religious groups since they are moral communities which usually exercise regulatory influence over members behaviour by providing normative statements about how people ought to act as well as sociological imperatives that define social existence for members on that note religious groups as perceived by adidome parents become partners in regulating adolescents sexual behaviours rather than as destructive social force discussion and conclusion the objective of this article was to analyse the perceptions of parents regarding the role of religion in adolescents sexual behaviour in two communities in ghana the analyses have showed that although there are existing moral mechanisms that regulates sexual behaviour religion was viewed as providing alternative moral system when parents perceived lapses within the traditional methods of moral regulation two major roles of religion in regulating adolescents sexual behaviours were thus observed religion inhibiting sexual behaviours and religion facilitating the learning of proper conduct governing sexuality in africa religion is said to be one of the essential aspects of life and its vital influence over sexual socialization in africa has widely been acknowledged in ghana religion and morality are bed fellows and study shows that religious teachings in ghana from all the three major religious groupschristianity islam and traditional religionsprohibit sex outside the context of marriage and thus views it as a sin religion has thus been found to exert the most influence on sexual socialization in ghana than the state and society though parents from somanya found aspects of religion counterproductive to the sexual initiation rites of adolescents the utility of religion was not denied parents from both communities found religion a significant factor with the potential of reducing the risks that come with early onset of sexual behaviour this is consistent with the findings of other studies that have identified religion as inhibiting adolescent sexual activity the influence of religion on adolescents sexuality seems to have been exerted through religious socialization the process by which a culture through primary agents such as parents encourages individuals or children to accept beliefs and behaviours that are normative and expected within that culture this was showed in the analysis by the way parents solicited religious leaders counsel and directions to correct a perceived deviant behaviour in adolescents this is consistent with the view that the family and the church are key agents of religious socialization and in ghana adolescent sexual behaviour comes under its serious influence the seemingly complete positive perception that religion exerts positive influence over adolescents sexual behaviour in adidome and the openness to view them as partners in socializing adolescents to be in line with normative standards of sexual behaviour could be explained by social capital theory according to king and furrow social capital theory conceptually demonstrates how positive outcomes are mediated in a social context through interpersonal associational and cultural social ties social capital is also thought to provide at least three forms of social support one of which is informational support the rest being communal and instrumental sometimes depending on the relationship one has with his community social capital may also provide emotional support as per the understanding of the parents in adidome judeochristian ethics serve as a veritable resource for the sustenance of the social capital of the people thus in essence parents in adidome might find that the opportunities provided by a church setting for intergenerational relationships and the shared code of beliefs that provide a social system which facilitate the development of moral behaviours might positively influence the moral lives and by extension the sexual behaviours of their adolescent children the observed existing communal socialization and proscriptive morality in the town do showcase some degree of normative standards that are in tandem with religious beliefs and thus facilitate a smooth collaboration between religious groups and local normative systems that regulate adolescent sexual behaviours such view seems consistent with the old african saying it takes a village to raise a child thus plausible to parents in adidome every system within the nexus of their sociocultural milieu is a cultural capital that must be engaged in the socializing of children the perceived tension between exotic religion and dipo rite in somanya could be understood within the larger discourse of the tension between christian ethic and a cultural practice as observed by steegstra dipo is linked to kinship ties reproductive health and it culturally constructed a krobo identity through the integrative aspect of the rituals nevertheless the ceremony like any other female initiation exposed the girls sexual attractiveness and virtually provided social license for sexual relationship which was viewed as contrary to christian ethic thus many christians who are krobo viewed the rite as a catalyst for teenage pregnancy and other immoral behaviour such as prostitution and do prevent their children from being initiated however those who are not christians do not subscribe to that view it is this tension which came to the fore when parents explored the utility of religion in regulating their children sexual behaviours additionally this reaction by parents from somanya could reflect underlying apprehensions about social injury from perceived adolescent deviant behaviour social injury is the ideology that a members misconduct affects the family or social group in general ghana is an interdependent society and the belief that another persons moral deviation affects the family is pervasive socializing children with moral virtues starts very early in life since honour or dishonour is shared parents in this town might be expressing the fear that their children will become a source of shame and dishonour if they escape from being initiated by traditional puberty rites unfortunately churches seemed to provide a route of escape as they brand anything beyond its theological postulations as fetish or devilish this could explain the seeming acrimony against churches as spoiling the children implications for hiv prevention in ghana the findings in this research have some implications for hiv prevention in ghana the first is that religion is an essential element in adolescent sexual education an important area in hiv prevention the analysis has clearly showed that the making of an adolescent moral personhood in ghana include religious socialization and this has been emphasized by previous studies with wider implication for justifying the importance of the integration of religious and moral education at the basic school level of the ghanaian school system religious education therefore should be viewed as an essential partner in hiv prevention religion has always been an essential element in hiv prevention in ghana for instance in the fight against hiv stigma religion has played a significant role in reducing the stigma and facilitating empathic responses towards hiv and aids patients secondly the cultural and traditional contexts and practices of the people should be considered when embarking on religious education undoubtedly certain traditional beliefs and practices and judeochristian ethics might be incompatible with each other nevertheless the study has showed certain areas at which judeochristian ethics and traditional mores do not collide this has been demonstrated in the community of adidome where there seemed to be a common goal of both sides converging in reducing adolescent risky sexual behaviours these areas are soft spots that could be courted for effective collaborative efforts from various belief systems in reducing adolescent risky sexual behaviours in a nutshell exotic religious education of adolescent sexual behaviours should be sensitive to the local culture to avoid any counterproductive clash in conclusion the study has showed that religious education of adolescent sexual behaviour is a major cultural resource for ghanas hiv and aids prevention efforts parents have consented that religious education is a viable partner in the socialization of adolescent sexual behaviours although there are potential spots that might affect the effective harnessing of religious resources and traditional cultural norms for adolescent sexual education in some communities efforts should be made to reduce them for effective engagements limitation of study this study has some limitations the first is that it is casedriven and thus the findings cannot be generalized to every community in ghana another is that the use of focus group discussion could discourage some parents from sharing other sensitive issues about their wards against the backdrop that within the interdependent social milieu in ghana a members misconduct could affect others and some parents are likely to hold back other information that might be sensitive although useful and richer for analysis the use of onetoone semistructured interview in the future could help to bring to the fore other indepth issues on adolescent sexual behaviour in the country

to understand the role of religion in the sexual behaviours of adolescents the views of parents who are key agents of socialization were examined from two southeastern communities in ghana focus group interviews were conducted with mothers and female caregivers of adolescents and one with fathers and male caregivers of adolescents thematic analysis was used to analyse the data findings indicated that parents from one community perceived religion as playing a doubleedged role in adolescents sexual behaviours as on one hand it played a protective role by restraining adolescents from risky sexual behaviours on the other hand it disparaged the existing traditional measures that regulated adolescents sexual behaviour however parents from the other community found a collaborative interface between the existing social control measurescommunal socialization and proscriptive morality with religious ethics religious socialization social capital theory and the concept of social suffering are used to explain some of the findings of this study implications for hiv and aids education and prevention are also discussed

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resumen este artículo analiza la agrupación del alumnado en la educación primaria y su influencia en alcanzar resultados educativos elevados el autor tiene como objetivo señalar los logros del alumnado como la interpretación educativa se construye en la interacción en el aula y como estas construcciones están conectadas con la interpretación del profesorado de las habilidades del alumnado el análisis está centrado en la interacción micro que ocurre entre el profesorado y el alumnado este estudio empírico está elaborado desde la perspectiva interpretativa y basado en las nuevas teorías sociológicas de la educación para la obtención de los datos se llevaron a cabo entrevistas con profesorado de lengua y matemáticas seguidas de entrevistas con alumnado a los que el profesorado describía como de altas capacidades o de bajas capacidades cabe destacar también que el análisis de los datos empíricos se realizó a través de un análisis crítico del discurso los resultados demuestran que ambos alumnado y profesorado legitiman una agrupación específica del alumnado que condiciona el rendimiento académico también es posible concluir que la interpretación sobre los procesos educativos que sigue el alumnado están condicionados por las interacciones que se dan en la escuela aunque se dé una relación entre interacción y rendimiento académico el profesorado tiende a explicar el rendimiento académico a través de otros factores education content pupil achievements school organization etc apply a simplified education system interpretation based on presumption that by putting in place a right kind of system organization one can achieve higher academic results such a perspective loses its connection to the context of every specific case which is the main argument for explaining various education praxes yet even such superficial analysis reveals problems and questions within latvias education system that beg for a much deeper research for example data from the central statistical bureau shows that 9th grade is finished by around 10 less pupils than started to study nine years ago in study year 20092010 around 3 of pupils who graduated primary school did not receive the certificate of completion but graduated primary school with a school grade report in year 2010 53 of primary school graduates decided not to continue their studies in secondary school in addition the situation outlined here does not correspond to the goals that latvias policy makers stress namely promoting a knowledgebased society and lifelong learning and ensuring education availability thus it is necessary to search for explanations which would allow explaining mismatches in the education system to ensure full understanding such explanations shouldnt be limited to a macro perspective within this paper i am addressing pupilteacher interaction interpretation during education processes the aim of this study is to analyze how the interpretation of pupils and teachers mutual interaction is used by both groups to construct knowledge about pupil achievement groups the research object is primary school pupils their teachers and both teacher and pupil knowledge about the education process it means that within this paper i use term education to refer to primary education the study is elaborated within the perspective of social construci t is common to view the education process in schools both in public and academic discussions from a macro perspective therefore discussions regardless of the issue addressed be it 149 remie multidisciplinary journal ofeducational research 3 tionism education processes are explained through the theories of pierre bourdieu and basil bernstein tracking and labeling ideas of both authors in this research are used to give explanation on how pupils belonging to a certain social group influences his abilities to act according to education agent expectations i am interpreting tracking and labeling as two sides of the same coin both are instruments that give real tools to agents involved in education processes to connect their knowledge on education process with the praxis that promotes specific education results during research interviews with latvian language and mathematics teachers and teacher recommended pupils were conducted in total 34 indepth interview data was gathered to analyze the empirical material critical discourse analysis was used theoretical perspective to explain my education interpretation i draw from several theories here the selection of theories is defined by my interpretation of hierarchical relationship between them mutual vertical relations of theories allow me describing education processes top down across the whole range from macro to mezzo to micro similarly theories are selected in a way that enables offering a logical explanation from several theoretically relevant education levels and keeping in under consideration the main education system traits these education system traits are as follows the presence of power on all its institutional levels specific interaction types high legalnormative regulation level and high ability to extrapolate education results theories ofpierre bourdieu and basil bernstein one of the best known perspectives on interpreting education has been elaborated by the french sociologist pierre bourdieu quite a similar view on education has been offered by the english education researcher and linguist basil bernstein both authors lived and developed their theories at the same time this has encouraged critics to suggest that both theories supplement each other yet several nuances of theories encourages us to make a clear distinction between both approaches the ideas proposed by both researchers can be integrated under the statement that education will offer differing opportunities for pupils from various social backgrounds achievement diversity shouldnt be explained through the overall level of schooling quality but as a linkage between the schools internal processes and the interests of the social and cultural elite in both cases education represents dialectical relations between the groups ability to legitimate dominant praxes and knowledge and its access to power as a result dominant groups can define categories which later are used to select individuals which are allowed in dominant groups such explanation proposes that firstly during the analysis education shouldnt be separated from the space it is located in secondly this shows how the school works as a mechanism for social reproduction ideas just mentioned and conclusions derived allow identifying some additional factors which unites both authors both bourdieu and bernstein describe pupils attainment of accepted valued knowledge as the main factor that can be used in identifying pupils high achievement ability bourdieu illustrates how school is constructed to strengthen symbolic capital and how education is used to reproduce culture capital bernstein shows how linguistic codes are used to promote pupils from certain social groups selection of classroom code is a result of pedagogic praxis used it is teachers interpretation of pupils abilities and capacities in both cases the level of achievement pupils will be able to show depends on the kind of knowledge the school accepts such knowledge is selected and legitimated by groups most effectively using symbolic capital in other words pupils representing groups that have access to resources influencing education praxis will always achieve higher education results another factor which should be taken into account when talking about education is that the school can create knowledge that later on will be accepted and used as a basis for defining social structure from the perspective of bourdieu and bernstein there is a constant conflict 151 remie multidisciplinary journal ofeducational research 3 within society over the authority to determine knowledge what will be taught in schools for group members access to education content planning guarantees both higher academic achievements for the group members children and the possibility to use school to ensure the value of such knowledge schools dont merely teach kids a predefined set of knowledge they demonstrate young people which knowledge is worth knowing as a result although most pupils cant achieve high school results they still accept knowledge offered in school as an instrument which can support their status and which can be used to restrict or promote their opportunities in future this short description of both theories allows us to understand the praxis which is used to reproduce pupils academic results yet although these theories give a clearer understanding of how pupil achievements are created both authors have only partially considered the pupil as an active agent both theories consider interaction which can emerge between the teacher and the pupil just in a context of accepted knowledge by doing so the authors ignore an important education agent the pupil and his interpretation and knowledge about the processes he is operating in therefore the question of explaining pupils achievements still remains a black box a problematic part of bourdieus and bernsteins perspective is their proposition that pupils act in a system where every meaningful praxis occurring is systempredefined its already inscribed in the accepted context and education system pupils in such a perspective are just passive objects of symbolic violence who do not have any real tools to influence the situation researchers have tried to correct such determinism for example ogbu has concluded that pupils minority group origins can influence their attitude towards the majority created education system minority pupils may be unwilling to get involved in the education processes other authors point out several other ways how pupils interpretations and actions can influence schooling outcomes pupils who hold different interpretation about their future opportunities show different academic achievements similarly pupil attainment can influence interaction within the classroom teachers interpretation of pupils and pedagogy used etc pupils academic achievements can be explained through various factors yet we dont have a clear view of how these factors could be connected arguments mentioned can be used to conclude that to answer questions asked we should focus our attention on agents mutual relations within the class on a micro level tracking to fully understand education mechanics it is important to define instruments which teachers can use to promote pupils achievement two concepts could be used to deal with this issue tracking and labeling both terms are commonly used in theoretical and empirical research and both are used to explain specific interaction which can occur between pupils and teachers and how this results in pupil attainment consequently the introduction of tracking and labeling allows for creating a much more detailed explanation of mutual relations between the educational praxis and the interpretation of education by the involved agents explanations of tracking usually contain some indication of hierarchical structures within school which at some point will promote different access to education resources jeannie oakes explains that tracking is a process during which pupils are divided in categories that later will be used to appoint them to classes or groups as an example oakes offers a distinction which she says is commonly used in schools classes can be divided in groups of fast middle and slow learners oakes points out that usually this distinction is supported by teachers and school officials because they accept the perspective that teachers will be able to select more appropriate pedagogic praxis if pupils are divided in ability groups although researchers cant agree on tracking consequences most of them tend to describe it as a negative praxis that should be reevaluated researchers point out that depending on the group or class to which pupils during selection are assigned several education factors change time spent for education knowledge taught pupils circle of friends opportunities for further education as well as access to some specific 153 remie multidisciplinary journal ofeducational research 3 knowledge etc commonly researchers conclude that more often the consequences will be felt by lower class pupils this can be explained by the fact that lower class pupils much more often are tracked into low ability classes additionally researchers suggest that considerable differences in average achievements cant be observed between classes were pupils are and arent tracked in grouped classes the achievement average stays the same because the dispersion of results grows pupils who are tracked as high achievers tend to get even higher results while pupils who are considered to be low achievers fall even lower authors often tend to show tracking as nearly a mechanical process during which the structure of society is reproduced and individuals from lower status groups are significantly limited such approach can be easily connected to ideas of bourdieu and bernstein that emphasize that cultural capital of lower social groups involves limitations when used to perform tasks associated with upper status groups tracking from such perspective represents interpretation of pupils ability by teachers evaluation of pupils ability to learn acquire knowledge and function according to school rules this description connects tracking to labeling labeling the usage of the term labeling offers a critical interpretation of education processes and helps to keep distance from the official view on teacher pupil relations it means that the concept of labeling allows the researcher to expand the borders of the school education processes and statuses of involved agents the concept of labeling has been introduced into sociology of education by ray rist rists definition of core characteristics of labeling fits well with the already given description of tracking where teachers interpretation of pupil ability comes from predefined ability categories selected by teachers to facilitate their work as mentioned if we use the term tracking then probably some clear context meaningful and measurable factors that serve as a basis for grouping will be observable with labeling we can clearly distinguish praxis results yet we cant notice the grouping m grivins pupil grouping and agent interaction influence processthere arent any public definition why some pupil is described as low achieving the labeled kid is taught in the same class as other pupils and the teacher may not even notice that his pedagogy and interaction differs from pupil to pupil officially labeled pupils dont receive any new status that would support the need of some specific model of interaction yet although there hasnt been any official changes within the school or class the teacher chooses to form different interaction and maybe even teach some other knowledge based on his interpretation of pupils ability the result of labeling is a selffulfilling prophecy the pupil starts to fit the expectations that are promoted by the teacher teacherpupil interaction has ensured that the teachers interpretation of pupils abilities turns out to be true and everyday observations confirm his expectations still there was not any real support for the teachers interpretation to start with and the only reason why the results correspond to teachers interpretation is his expectations which have promoted unequal resource distribution within the class we can associate such point of view with the fact that pupils come to school with their social luggage certain cultural capital that defines ways of how pupil works with knowledge and how he chooses to represent himself meanwhile the teacher comes to school with his social experience that is used to create more effective pedagogy to give a more precise labeling interpretation i would like to point out some final remarks firstly pupils can be labeled on a wide range of factors most commonly labeled characteristics in education are drawn from the space that we could call meaningful context the space were school is located and were teachers experience is shaped secondly although a label is attached to every single pupil at the end the classroom will be filled with wider pupil groups where every pupil may be connected to several labels thirdly all of labels will tend to connect with the ability to explain academic achievements fourthly every characteristic which is labeled will tend to legitimize itself legitimization should promote two observable consequences firstly labeling arguments will tend to connect with socially accepted arguments and secondly within the class there will be a search for ways how to legitimize pupil results methodology in the previous sections of the paper i showed how interaction within the class can promote specific academic outcomes here i argue that to predict pupils academic abilities various unorganized knowledge from the context is brought into everyday classroom interaction integrated knowledge then generates teacher and pupil expectations towards the specific pupils ability to execute everyday tasks that can be used as a factor to explain his achievements differences that can be observed in teachers interpretation with regard to various pupils are based both in his pedagogical experience and experience obtained outside of school such experience is manifested through everyday pedagogical praxes the teacher who within the school is in a power position can use the authority accessible to him to promote interaction that would support his general beliefs about pupils skills and abilities as a result the pupil interacting with the teacher is forced to accept the role assigned by the teacher teachers interpretation is based on his knowledge he uses certain constructions that would legitimate the truth of social praxis this means that the main element conditioning teachers knowledge and his ability to carry out pedagogic praxis based on this knowledge is language to supplement and explain this point i should mention that here language functions consist of accumulating knowledge defining what is possible conditioning power relations and forming reality for bourdieu and bernstein language also is an instrument that creates borders between groups to analyze how pupils are grouped within a classroom 8 interviews with mathematics and latvian language teachers of 8th and 9th grade and 26 interviews with pupils were conducted in total i visited eight schools and in every school one teacher and several pupils suggested by teachers were interviewed teachers were asked to suggest the highest ability and poorest ability pupils in the class for interviewing and during the interview they were asked to explain their choice the obtained text was analyzed using critical discourse analysis compared to other similar perspectives cda draws a great deal more attention to power relations that can be observed within a discourse as a method cda does not involve significant limitations for m grivins pupil grouping and agent interaction influence its usage on the contrary it encourages researchers to adapt the method for their needs and to select instruments that fit best for a specific situation the main restriction for cda usage is that the theoretical basis selected should emphasize power relations with characteristics mentioned in mind it is much more easier to describe cda not as a method but as a principle or perspective used it is more an approach that stresses researchers point of view with regard to social processes ruth wodak points out that it is better to describe cda as a perspective that can unite several approaches teun adrianus van dijk defines that cda is not a specific research direction and that is why it doesnt have one precise theoretical frame norman fairclough stresses that optimal cda usage is possible only of differentiation and crossdisciplinarity is encouraged an oversimplified explanation of cda could be that it is a method that tends to make more visible the links connecting discursive praxis social praxis social structures and text another explanation could be that cda explains through power relations the links that affect every social event as well as text usage yet remain unnoticed during everyday text construction and usage usually this method is associated with an attempt to observe dominance discrimination observable and hidden power and control within language interpretation that illustrates cda presupposes that language dialectically connected to various elements of social reality is an inseparable part of this reality it just means that while researching social reality we should draw our attention to language and language research can be a productive research field cda explains reality through language analysis to be more precise i should mention that by using the term language i mean language usage or if i use more common terminology text text as a research object can include any praxis of language use starting from everyday conversations continuing with books and finishing with focused interviewing interpretation of text can be widened to text as cultural artifacts such as music a picture on the tv screen or as a matter of fact tv itself such differentiation is based on the argument that a text always includes two characteristics representation and interpretation both characteristics can create new links and restrictions that emerge from social praxis and factors brought up by a social situation relaying on the mentioned arguments fairclough defines discourse as language use influenced by social praxis cda will always draw its attention to power relations that can be observed in text we can distinguish between two ways language is linked to power relations firstly power relations are located behind and within language and secondly power relations emerge from restrictions in language usage from social praxis that regulates interaction it means that every text is simultaneously connected to power relations reproduction of power relations and restrictions in situation interpretation in this way discourses are always connected to ideologies and hegemony of certain groups michael foucault while describing constructing and structuring characteristics of discourse points out that discourse as a connection between a wider social formation and observable text usage constructs and positions subjects it means that discourse constantly shapes and deforms objects that are connected to its usage and by doing so discourse constantly draws borders and power relations from foucaults perspective power relations are shaped through defining what is true and by attributing this definition to physical and social reality here discourse emerges as a mechanics that allows defining and maintaining a social position by giving opportunity to define themselves and others in this paper i am using text analysis to explain how teachers and pupils group pupils to make my explanation deeper i draw my attention to situations when grouping occurs and to the context of grouping praxis i use n faircloughs three dimensions of discourse analysis as a basis of my analysis this perspective prescribes that the researcher should start analysis with discursive praxis interpretation follow up with text description and finish analysis with social praxis interpretation in this part i will present results of my research i have tried to group findings in three sections yet in many cases it isnt possible because of amount of conclusions that are overlapping and can be fitted in every section that is why i show some of the findings just by selecting where they would fit better in the overall story the first section of findings addresses the overall explanation of how grouping can be interpreted and how it fits the official or unofficial praxis of the school the second section is concerned with arguments used to legitimize grouping or other praxis what doesnt fit official school or state policy the third section questions characteristics of groups created and shows how arguments are chosen for creating groups results interpretation of optimal education is shaped by latvias education legislation international regulations and agreements as well as public opinion in total these agents produce a nonexistent utopian education vision where every pupil shows or can show high achievements and every teacher is highly involved in the development of every pupil here i wouldnt like to expand an interpretation of the accepted education perspective yet i want to point out that in a perfect system pupil grouping isnt acceptable and it cant be interpreted as a part of technologized education discourse discursive form that represents accepted perspective of educational praxis and education characteristics that is why ideas of grouping are brought in informants stories and they search for ways to legitimate it such legitimization praxes are interesting from several perspectives firstly they illustrate teachers interpretation of the characteristics of grouping that make it acceptable and the possible use of identified characteristics in legitimizing a praxis that lies outside technologization secondly it allows observing the kind of knowledge teachers tend to bring into technologized education interpretation to begin with i have to point out that while talking about everyday education praxes both teachers and pupils use several official and unofficial categories to group pupils informants show that grouping is grouping praxis 159 remie multidisciplinary journal ofeducational research 3 part of everyday education praxis that needs to be supported because firstly by doing so the teacher would be able to pursue best pedagogical praxes and an optimal education process secondly power relations that are necessary for a successful education process could be reproduced and strengthened through grouping yet such praxis shouldnt violate some vague borders that are defined by technologized interpretation grouping seems to be a logical result of distribution of power and the necessity to maintain it yet it acts against meritocratic ideals in education knowledge and power in the education system can be linked in several ways technologized discourse holds an understanding of authority of the wise competent teacher and subordination of pupils willing to learn those involved in education interaction expect that the power positions the meaning of authority and the ways the power is practiced will change depending on the status achieved in the education system in school one can observe a hierarchy of knowledge which directly influences power distribution and usage and it is directly connected to the social position that different agents in the class have pupils development is organized in a gradual manner every day they learn something new however achievement control is organized regularly it is not practiced constantly teacher monitors pupils by asking them questions followingup if they have done their home assignments he repeatedly interacts with the pupils he is not sure about or whose achievements should be improved at the basis of interaction described is the assumption that regular control will promote pupils attainment in the education system at the end the pupil will realize that conflict relations with the teacher arent optimal so he will change his unacceptable interaction yet pupils while talking about such processes comment that it just makes them less positive about the education process as such basic interpretation of grouping in pupil and teacher interviews is connected with pupils abilities to correspond to some overall expectations about pupils academic achievements at a given age it is a perspective of optimal development that is connected to a very wide context both in and outside school optimal development here is viewed as a possibility to receive acceptance for being in power positions a pupil who is developing according to teachers evaluation of the right way can receive more power in deciding for himself on optimal schooling schedule interaction etc heshe receives the opportunity to avoid being the target of some power practices that the teacher uses in the classroom development is similarly described by pupils however they put more emphasis on physical development by pointing out that age itself can serve as a tool for changes in power relations it shows that pupils see changes in power structure as inevitable and not necessary connected to invested work while the teacher can interpret everything through invested work even biological age within school one can observe a much more differentiated inner age distinction which is created by connection to knowledge development biological age and behaviorally manifested age to be more precisepupils have to fit expectations in several ways and all expectation perspectives can be used to describe him and make conclusions about his academic abilities depending on processes one is talking about both teachers and pupils can select any of these factors to prove a point they are trying to defend although there is a certain power attached to every successive stage of age the pupil cant just use it according his biological age a more complicated perspective presupposes that age requirements should be fulfilled with regard to all factors so the teacher and the pupil can subtract somebodys power by pointing out that according to some criteria the person hasnt reached the age of power for example during interviews respondents were using such expressions as they behave like small kids knowledge they dont possess is taught in the fifth grade this they had to know a year ago etc to conclude i should summarize that grouping is about granting or banning access to power positions pupils expect that by growing up they will receive more possibilities to decide for themselves yet teachers using several instruments grant power only to those whom they evaluate as worthy of power distribution can be explained through the teachers expectations which the pupil can match and fail to match in several ways argumentation for grouping as i mentioned earlier there is overall agreement that education should be represented and perceived as a technologized form nevertheless 161 remie multidisciplinary journal ofeducational research 3 rather often something that doesnt fit into technologized form is brought out as part of it in such cases agents tend to search for ways to support interdiscoursivity there are several ways in which teachers and pupils tend to link pupil grouping with technologized education interpretation pupils usually are well aware of principles used as a basis of grouping they can identify several pupil groups in the class and explain why the concrete pupils are in the group however they use knowledge on grouping with a different aim with grouping they accept some class principles as obvious and legitimate such approach allows them avoiding full involvement in education processes in other words pupils use grouping to legitimate their low involvement in school rituals and other praxes as a result pupils who are labeled as high ability are forced to learn while those who are poor ability can avoid it one of the first arguments used to justify grouping is professionalism informant argumentation suggests that the grouping of pupils serves as a proof of teachers professionalism both teachers and pupils stress that pupils involved in education are different and they represent various needs teachers ability to promote interaction that is based on this differentiation illustrates his professionalism and serves as a basis for pupils opportunities this perspective to depict grouping as a natural part of education automatically accepts the line of different arguments as selfevident the most obvious example of selfevident knowledge is the statement that pupils differ by their abilities knowledge interpretation etc to such an extent that adaptations in teachers pedagogy are needed this perspective is used commonly automatically connecting it to other statements describing teacher professionalism which can again be seen as factors describing the way that pupils are grouped for example teachers tend to describe how they coordinate pedagogical praxis with other teachers teachers agree on common interpretation of the pupil and his achievements and agree on what they expect from this pupil comments like these are used to illustrate teachers professionalism and care about the pupil pedagogy from this view point is based on needs of every pupil it is and should be separated from some distant external regulations all arguments used are closely connected to an argument that could be called environment a pupil is part of an environment that helps teachers explaining what this pupil is like to explain his abilities and achievements teachers tend to talk about pupils parents family values place of living and lifestyle peers etc they use pupils private experience with a certain group as an argument on how such a pupil should be educated or what he can achieve even the fact that the teacher doesnt know anything about the pupil can serve as a basis to come to conclusion that the pupils parents arent interested in education of their children in a similar way teachers tend to use other information accessiblesmall everyday facts whether and how the pupil buys lunch in school may be used as an argument to illustrate that the pupil is facing economic problems the pupils friends can be used as evidence that illustrates the pupils interests and leisure time activities again the ability to deduce weighty conclusions from small details is represented as proof of the teachers professionalism commonly such arguments arent used separately but as a part of a wider explanation another nuance that serves both as a proof and a reference for showing that teacher is not prejudiced is the teachers ability to distinguish whether the mentioned observation on the pupil is important in order to demonstrate that they are not prejudiced teachers tend to explain how they have managed to distinguish exceptions where seemingly obvious hints were wrong one more argument used by both teachers and pupils is natural development this argument presupposes some mental background and natural limits of pupils abilities it means that pupils inability to achieve certain results should be explained through pupils intellectual limits rather than by teachers lack of professionalism yet there is one more way to speak about pupils mental capacitiesto explain that some pupils are not meant for this knowledge pupils point out that they cant be good in mathematics or physics because they are artists they dont have mathematical thinking in same way teachers tend to label pupils as artists or scientists thus explaining why the pupil doesnt show equal results in all subjects the forth argument to legitimate pupils grouping is knowledge continuity teachers classify pupils abilities by pointing out that there 163 remie multidisciplinary journal ofeducational research 3 has been discontinuity in hierarchical development here the informant uses an assumption that knowledge development is a hierarchical process and it isnt possible to obtain knowledge if one hasnt mastered its previous levels as a result the pupil may be unable to master something because at some previous stage he hasnt been exposed to the right kind of pedagogy this argument can be used both by teachers and pupils who can explain their present achievements by mentioning something that has happened earlier and cant be changed the reasons one hasnt learned previous knowledge can differ greatly it can be that the pupil has missed a great deal of schooling or he wasnt motivated to learn or he has been exposed to week pedagogy this argument is interesting because of the idea of discontinuity of hierarchical development this term helps explaining how guilt about unsuccessful learning teaching process can be passed to whatever agent in the past a teacher can point out that he cant teach the pupil because he has missed certain basic learning in his family or because a previous teacher hasnt done his teaching work well a pupil can explain that his former teacher wasnt good at teaching or that he himself didnt want to learn the last to describe here is the comparative argument comparison is based on experience which can serve to compare a pupil a class a school to another pupil class or school teachers commonly use comparison to illustrate his former or uptodate achievements or just to illustrate his knowledge over the field again such argument allows legitimating certain achievements most commonly comparison is made within one class between classmates a more complicated case is when comparison is created between two or more classes teachers can compare to some former classes to former pupil generations to pupils parents to other schools in the district or the best schools in the state etc by choosing the object to compare with the teacher manages to illustrate every point he is trying to make comparison is drawn from the informants immeasurable context yet the form of explanation is shaped as the general truth the agents involved in the education process can associate any pupil with several interpretations connection to a specific label can be interpreted by both teachers and pupils labels can be provoked by separate events by some explicit characteristic by ability to integrate into the class group relatives etc knowledge about a pupil can emerge fast and tends to be persistent interpretation about the pupil can be practically unchanged yet arguments supporting such interpretation change involved agents search and replace arguments to create a more precise and enduring label yet some arguments can be mentioned even if they reflect the situation that occurred several years ago during some interviews teachers use the term stigma underlining that interaction contains prolonged and persistent knowledge that may hold negative attitudes usually teachers in interviews doesnt use terms that hold such provocative meaning and prefer much softer pupil interpretation descriptions teachers also mention that their knowledge about the taught class may influence interpretation used to interact with pupils other important factor is pupils selfidentification this definitely is a vast question that is linked to all education praxis if not provoked pupils rarely tend to give meaningful selfdescription which would be directly linked to education discourse by using pronouns and pronominals pupils draw connections with classmates class and school as an opposition to another school a parallel class or other classmates yet none of such identifications are directly connected to the school although all these categories at the end can be used by somebody to describe the pupils achievements they dont have any direct connection to influence pupils achievements one explanation that could be used to clarify why pupils practically avoid identification with the school is that for pupils who dont show high achievements the school doesnt offer any significant status the only status offered to pupils is pupil as a result most of them dont identify themselves with knowledge they are obtaining or have already obtained yet although pupils are not able to identify themselves within the education process they are able to describe affiliation with their grouping and status 165 remie multidisciplinary journal ofeducational research 3 their school and class mates even more pupils can identify the label attached to them and identify the labels influence on his opportunities for example a pupil may identify himself as slow and describe that it is the reason he has to learn for longer time than other students however pupils demonstrate a more clear connection to the school and education when they are describing classmates pupils often give insight on classmates relations to the teacher and the school and mention their marks and success in school even more pupils tend to explain classmate achievements both through some personal characteristics and their relations with teachers i would suggest that pupils notice that success can be explained through teachers attitude toward the pupil yet during interviews they reproduce arguments teachers use interpretations of pupil achievements are constructed depending on the school context which is both contexts outside and inside education system an additional observation is that when describing classmates school achievements pupils commonly use more than one criterion pupils are simultaneously using several arguments and most are just some conclusions drawn out of one of several contexts out of the education discourse a more clear description of pupils is given by teachers teachers give comments that there are pupils that are mentally challenged and that teachers in everyday pedagogy have to deal with that for teachers pupils may be problematic hard to teach spoiled ailing etc teachers use a wide range of different and often metaphorical characteristics to describe pupils inability to fulfill his expectations such labels arent hidden behind the technologized form of education discourse but legitimized through offered legitimization arguments and then represented as a proof of teachers professionalism ability to distinct pupils problems and react based on these conclusions pupils illustrate that there is a connection between teachers knowledge about the pupil his individual interpretation about the group he is representing the pupils ability to act so that he would be liked by teachers and the pupils marks to be liked by a teacher can be gainful and most pupils not just know that but can describe strategies employed to become likable quite common is that pupils are described in comparative categoriesthe description is based on some meaningful oppositions knowledge that underlies such oppositions doesnt differ from school to school mainly such distinctions are constructed around pupil categories of who can or has achieved high results and around those who dont or cannot do it the group of pupils who dont show high achievements consist of labels such as idlers shortchanged by god slow developing kids from disadvantageous family here teachers use social mental and physical arguments at the same time showing that for every pupil there is a line of maximum knowledge that he can achieve and if he knows more its a proof of the right pedagogy some teachers start their description of a class with a relatively mild pupil achievement description lower end such a label could at least theoretically be interpreted just as a description of schools academic achievements yet further in his story the teacher would start to use other forms to describe lower end pupils he refers to the group as the bad ones the second meaning of this latvian word sliktie would be villains obviously the last pupil description is much deeper and holds wider interpretation of meanings one pupil uses the term the good list which is meant as a group of good pupils if youre not on this list there is a considerable possibility that you wont have access to the schools resources in their stories pupils often draw a close link between class achievements and teachers sympathies this shows that pupils are well aware of the distinction between accepted and unaccepted pupils in some interviews stories suggest that teachers work with pupils whom they like yet other kids are left on their own their contact with the teacher more often is described not through teaching and knowledge but through constant testing constraints and control although teachers tend to use a technologized interpretation of education at some point labeling can be used to prove that technologized discourse and accepted knowledge can be far from the context in which local school is based this is just a way how oppositional knowledge finds direct way to school to support struggle for power i have shown firstly pupilandteacher interaction in the classroom secondly their interpretation of education processes and mutual interaction and thirdly pupil grouping mechanisms and their connections to pupil achievements in order to demonstrate these issues i started with defining the basis of interpreting education processes and education system with the help of bourdieus and bernsteins theories i was able to illustrate processes that influence pupil opportunities within school namely the school functions based on accepted knowledge that is needed to grant success for oneself yet obviously this explanation isnt adequate because it doesnt give any real tools that agents could use to influence pupil achievements this is the reason why two more terms tracking and labeling were introduced together they show how expectations for certain knowledge and selfrepresentation can affect pupil and teacher mutual relationship and interpretation two factors that can be used to explain pupils marks in my analysis i showed that mutual interpretation influences pupils achievements yet a lot more interesting conclusion is that pupils are well aware of the scheme i described above to be more precise they can describe how teachers interpretation can influence the marks they receive and their everyday relations with the teachers one of labeling theory arguments is that if a pupil is addressed with the same interpretation persistently eventually he will respond according to expectations this argument could be used to explain my observationpupils tend to accept the teachers interpretation because they believe they fit teachers description this line of argumentation however leaves one observation unexplained although some pupils are well aware of variations in teachers communication and they accept that they are not as bright as other students they still say that if they only wanted to they could change the patterns of interaction pupils explain how one can achieve that he is liked by the teacher and can reflect what benefits he would achieve if he could gain teachers sympathies yet they choose to remain in the position they are placed in this could be described as a clash between what pupils actually know and what they do one logical explanation that i could offer is that school the place discussion m grivins pupil grouping and agent interaction influence where interviews were conducted influences pupils explanations and interpretations in school authority relations are deformed and pupils tend to give the right response as they would respond to a teacher yet the interview situation is new to him so he doesnt know what would be the right answer interviewer expects and he just chooses one he has heard from teachers and reproduces the story of the agent who within the school is an authority this suggests that pupils reproduced teachers views so there isnt any label stickiness just a willingness to give the answer which wouldnt lead to punishment it means that there isnt any contradiction pupils just dont want to be liked by the teacher in this way they are representing their opposition to the education system yet another explanation would be that pupils are putting blame for their poor results to the system they acknowledge that they arent succeeding and that they arent involved in classroom work in a needed level to change something they dont want to be guilty for that therefore accepting a label and showing that the system is corrupted is a way to prove that there are other reasons why they avoid education tasks the perspective that has been illuminated by my work is that during education research much more attention should be drawn to education institution context most of the questions about education that are there cannot be answered without context references although school is a selfcontained space with its own power structures and rules it seems that it still is an institution which can function just because of context dependent education interpretation a school is rooted in local society by strong ties that are unnoticeable if observed from a distance to explain what actually is happening a considerably more involved research approach is needed

this paper analyses pupil grouping within primary education and its influence on pupils opportunities to achieve high education results the author aims to show how pupils achievements and education interpretation are constructed in classroom interaction and how such constructs are connected to teacher interpretation of pupils abilities the analysis is concerned with micro interaction occurring between the teacher and the pupil the empirical study is elaborated within the interpretative perspective and based on theories of new sociology of education and grouping to obtain data about the questions analyzed interviews with language and mathematics teachers were conducted followed by interviews with pupils whom the interviewed teachers described as high ability or poor ability to analyze the empirical data critical discourse analysis was applied the results show that both pupils and teachers legitimize pupil grouping and these groups are used to predict pupil performance it is also possible to conclude that pupils interpretation of education processes comes from interaction within school although there is a link between interaction and pupils achievements teachers tend to explain pupil achievements through other factors

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development on their campuses for burgeoning student activists and to promote organizational learning to better implement institutional missions literature review this literature review focuses on the ways in which social media have been used to challenge inequality and the efficacy of such approaches here i use the definition of social media provided by junco as applications services and systems that allow users to create remix and share content thus social media activism is the act of using such platforms to achieve social or political change uses of social media for activism social media platforms have provided opportunities for widespread engagement and instantaneous feedback with few resource constrictions applications and websites offered a range of functionality to students with specific capabilities in constant evolution to meet the needs of users students used platforms to share information hold each other accountable and foster learning opportunities moreover these spaces operated beyond traditional communication hierarchies providing users with a high degree of utility and access for example social media has facilitated student activism through inperson and online action for both individuals and groups through these uses participation in social media resulted in formal and informal learning spanning interactions with peers and campus offices individual identityparticularly gender race income and education levels influenced social media usage socioeconomic status has determined ones access and ability to engage online past research identified gender differences as women pursued personal connections online while men valued invitations and announcements in terms of race african americans experienced higher levels of diverse online contact and spent larger amounts of time on social networking sites one explanation for this discrepancy is that social media allowed marginalized students to form connections beyond their physical environments such as black students at predominantly white institutions however social media sites also perpetuated issues of oppression it is perhaps unsurprising that white students reported more desirable racial climate experiences and lower levels of online stress than their peers nuance across different social media platforms suggested that students select different online environments based on preexisting social networks reaffirming connections with likeminded or similarlyidentified individuals as this research sought to understand how students use social media to promote change it is important to note the existing digital landscape much research explored the ways that social media have facilitated activism features that allowed users to like share and comment aided individuals in publicizing issues or mobilizing for action twitter gave rise to hashtag activism or activism in which users express opinions share information and connect to others by using a shared phrase and tag denoted by the symbol bonilla and rosa noted that hashtags allow users to organize their comments and to participate in dialogue they cited campaigns on twitter aimed at challenging police violence towards youth of color as examples of resistance to racialized victimblaming within the media even changing ones profile picture has emphasized broader solidarity with an issue although online support has been critiqued as less valuable even dismissed as slacktivism these actions challenged microaggressions and highlighted important causes thus social media served varied functions depending on the cause and participants efficacy of social media for creating change marginalized individuals experienced invisibility tokenization and misrepresentation daily within higher education social media have spread biased or oppressive content widely while silencing individuals harmed however social media also provided spaces to respond to instances of oppression and bias the various formats supported by social media allowed individuals to attempt difficult conversations from within their comfort zones senft and noble cited examples of youtube videos that exhibited funny and smart responses to racist incidents to critically examine current events and to offer an alternative perspective george mwangi and colleagues examined the i too am social media campaign that began at harvard in 2014 as a tool for black students to resist microaggressions and to address hostile campus climates through online counterspaces in another example hall shared the idea of a cue card confessional in which individuals used images and writing to subvert the gaze to which they were subjected aligned with other forms of campus speech that have both problematic and positive manifestations social media highlighted similar challenges with a larger reach for students attempting to engage in online activism these challenges and benefits have impacted how effective social media were in creating social or political change hashtags linked unrelated information to causes obscuring relevant information online movements struggled to move forward without clear organization stymied by their flat and decentralized nature there also have been individuals barred from engaging in social media activism due to limited online access or time finally it is important to note that social media activism have had mixed results based on individual values and approaches kristofferson white and peloza contrasted meaningful and token support defining the former as requiring cost effort or behavioral change to tangibly benefit a cause unless a public action aligned with individual values then private measures were more indicative of continued support and involvement in a social media context individuals without a commitment to a specific cause were likely to engage in future support if they participate in a private gesture rather than a public gesture however for people whose values are consistent with the cause a public gesture can affirm support and connection such findings have suggested nuances related to social media that are important to understand social change conceptual framework this study utilized the higher education research institute leadership model for social change later deemed the social change model the model examines how cocurricular experiences create powerful learning opportunities for leadership development through collaborative group projects that serve the institution or the community action is driven by seven values across three different spheres an individual level focusing on the consciousness of self congruence and commitment a group process that focuses on collaboration common purpose and controversy with civility and a societal value of citizenship these seven values have a reciprocal impact together they lead to an eighth value social change leadership is an emerging process shaped through interactions across the spheres in examining social media usage these spheres related to the elements of individual retrospection group engagement and societal connection that occur as student leaders engage online to create social or political change this study expands upon the social change model by examining how social media expand traditional boundaries to create immediate feedback loops and decentralized communities that shape individual and collective experiences design and method this study used a convergent mixed method design to explore undergraduate student leaders attitudes and behaviors regarding social media as tools for social or political change quantitative survey responses and qualitative interview data were collected concurrently and integrated during data analysis to gather a more comprehensive understanding of the topic this study uses a pragmatic paradigm to draw from both quantitative and qualitative traditions to answer the research question research site and sampling procedure the sample site was a large public research institution referred to as research i sent a recruitment email explaining the research study and providing the link to the survey to the primary student contacts listed within the sao organizational database to be eligible participants needed to be over the age of 18 enrolled as undergraduate students and hold a leadership role in a registered campus organization as ru only identified one student leader per organization snowball sampling was used to recruit additional participants by asking the initial contact to forward study information to peers in leadership roles data collection a survey was used to gather information on participants attitudes and behaviors the survey instrument was piloted with similar demographics prior to use to support reliability and validity questions fell into five categories data analysis as a pilot study analysis of the quantitative data primarily used qualtrics software to generate descriptive statistics only complete and nearcomplete cases were analyzed listwise deletion was used to remove cases with more than 20 missing information data was not weighted qualitative data were coded through constant comparative analysis a technique originally developed as part of grounded theory and expanded across qualitative research merriam and tisdell outlined key steps of the analysis as open coding in which the researcher examines initial materials and notes down any items that could be useful axial or analytic coding to group together comments that are similar continual revisiting of these codes with new documents to add to the master list construction of categories and themes that capture patterns across the data my approach was both inductive to examine themes emerging from the data and deductive to compare new data to see if it matched with the emerging framework after analysis on both data sets i integrated quantitative and qualitative findings data quality and limitations to maintain data quality i triangulated quantitative and qualitative information for the qualitative interviews i shared the final analysis with participants so that participants could comment on what was learned with and about them strengthening the authenticity and accuracy of findings i also engaged in peer debriefing with experts on student activism to test emerging findings nonetheless the study has several limitations the data came from a small sample size from one institution participants selfselected into the study and were students that felt passionately about social media and activism the size and sampling strategy limited the complexity of statistical analyses that could be conducted on the quantitative data beyond descriptive statistics identity can impact social media activism here most participants identified as white and information such as social class was not reported thus this study does not capture the full nuance of how identity may impact social media use for social or political change findings the survey respondents spanned undergraduate class years with 1837 identified as firstyear students 1633 as sophomores 3061 as juniors and 3469 as seniors most participants identified as women and white while individuals could hold multiple leadership roles across organizations the most common was president director or vice president category the most popular organizations included student governance advocacypolitical cultural or service four students agreed to participate in qualitative interviews all names are pseudonyms while organizations and roles are aggregated to protect participant anonymity usage of social media for activism consistent with national trends quantitative findings revealed that facebook was the most popular social media platform the next popular were snapchat instagram and youtube most participants logged in to social media all seven days a week when asked how much of their social media use is related to activism most stated less than half in describing their engagement in social media activism most participants cited publicizing events connecting with likeminded individuals and learning about current events as the primary functions utilized qualitative participants described using social media to respond to current events and to find their voice during a time of growing awareness while kate and fred arrived on campus hoping to create social change all four participants shared that exposure to new ideas during college increased their desire to confront inequality the social change model defines this individual value as consciousness of self in which individuals are aware of beliefs and values that motivate their actions for maeve exposure to programs on sustainability led her to shift career goals and advocate for conservation early in his time on campus fred impacted a campus policy through a role in student governance that fueled his desire to facilitate local politics kate described higher education as a call to action for herself and peers there are so many social movements going on right now with our generation and college and i think that people are really into these big ideas of change people seem more willing to post things they feel strongly about on their own pages amidst growing individual awareness there was a sense that participants used social media to respond to current events and to develop their opinions these actions allowed participants to be congruent across their thinking feeling and behavior maeve and bobby carefully cultivated what they shared to fit their personal approaches bobby was selective and intentional highlighting one key issue per day maeve also described her approach as selective but relied on humor i dont post too too much i dont post any opinion stuff i will definitely post things that imply what my opinions are…it is once in a blue moon that i will comment on something that i disagree on the only time that i did it was when it was my best friends boyfriend posted something that was personally offensive to me so i just commented something like watch it in this way participants utilized individualized approaches to address key issues additionally multiple participants integrated the organizational social media accounts used in their leadership roles with their individual profiles maeve and kate directly oversaw the social media pages for their organizations while bobby was in the process of assuming leadership for his politicaladvocacy groups accounts these participants saw their work in organizations as an extension of personal efforts to create change often sharing content across pages to draw maximum attention not only did this show congruence across multiple aspects of their identity but allowed them to demonstrate their commitment to social change maeve described i use facebook for my club i share things from my clubs account instead of my own and then sometimes i will then share it from there i do that to get people to like the page then people who already like the page will see whatever is there working in tandem with organizational pages helped participants to reach a broader demographic rather than viewing personal and organizational social media platforms distinctly creating synergy between the two helped participants to facilitate their goals perceptions of social media quantitative data showed that participants believed the most important functions of social media for activism were publicizing events and learning about current events participants saw social media as important for activism broadly but even more than for their individual efforts most participants stated that liking a post group or page served as a form of social media activism supporting the quantitative findings all four interview participants agreed that liking a status or article could serve as a form of activism participants noted that liking was a public act visible to others through features such as newsfeed in facebook as a result liking showed an individuals congruence and commitment to pursuing social or political change kate noted it will show up on someone elses news feed that you liked that post its less passive than it could be if it didnt do that liking could also make a news item more prominent helping to amplify its reach fred shared his belief that liking an item may impact facebooks analytics to make that post show up more frequently for others finally bobby added the cumulative impact of likes may be able to demonstrate broader social opinion and emphasize forms of solidarity he noted its a way of being able to keep track of everyday action of people and their thoughts instead of just a loud minority you can get more passive information better and so you can get a better aggregate sense of what people are thinking however even while arguing that liking could count the participants still noted that it was the least meaningful of the potential actions that individuals could take while a commitment it was minimal maeve shared people are going to read and support what they think that they read and support bobby and fred mentioned the idea that there may currently be a disconnect between gaining collective input through likes or comments and actual action both argued that must legislators and decision makers use social media to gauge public response fred shared that i know the politicians that are in office right now a lot of them are not in the millennial generation some of them dont have social media they dont necessarily see the amount of likes necessarily so theyre not going to be influenced while liking was valuable its impact was limited while social media platforms aided communication and demonstrations of solidarity the tools were ineffective to change others beliefs while the two men hinted at this belief taking care to post information that individuals would consider the two women were explicit about these limitations maeve noted i personally dont see a lot of value in having facebook debates where only two or three people are going back and forth nobody else is really reading it and nobody is going to budge kate shared its easy to make something sound legitimate when its not especially if youre telling people who wouldnt know either way the social change model describes the group value of controversy with civility as respect for others a willingness to hear each others views and the exercise of restraint in criticizing the views and actions of others here participants did not feel that social media platforms were fruitful spaces to engage in difficult dialogue they were also cognizant that social media activism could fuel complacency and deter individuals from more impactful actions kate and maeve explained that social media could lull individuals into a false sense of impact with the former describing the ability to fall into a pit in which a lot of activism is happening online and nothing is happening in the real world participants saw value in online actions but only when integrated with inperson actions discussion this study examines the research question how do student leaders use and perceive social media as tools to create social or political change findings show that participants use social media to act upon a growing awareness of social and political causes by using their voices to support concerns and enhance visibility while participants consistently described social media as important for their activism qualitative interviews illuminated the need to avoid complacency with online activities instead participants emphasized the need to use social media amongst many tools to work towards change connection to social change model the social change model suggests that action occurs across individual group and societal spheres in this study participants engaged across these levels through social media often simultaneously in ways consistent with oncampus leadership development however the data collected by this study focused primarily on individual values of consciousness of self congruence and commitment of the qualitative participants only maeve provided a concrete example of group values when her cultural organization worked collaboratively and with a common purpose to confront injustice on campus otherwise elements of group and social values were relegated to the background of participants experiences as such these findings focus primarily on one sphere of the model for students using social media to engage in social or political change all three individual values worked collaboratively to support leadership efforts the first value consciousness of self requires students to be aware of personal beliefs values and attitudes participants experienced a growing awareness of social and political issues upon their arrival at ru however there was some divergence around how much social media activism played a role in developing students awareness across the quantitative and qualitative results while survey respondents stated that social media educated them about current events interview participants highlighted the ways in which information posted on social media could be misleading or ineffective it is important to note that this study took place during spring 2016 during the campaign period leading up to the presidential election of donald j trump the national discussion on available misinformation had a pervasive impact on how individuals viewed current events and made important decisions this finding affirms other research on the ways that social media enables individuals to share such misinformation or express solidarity without a corresponding examination of the factual nature or potential biases present the impact of false statements can create a bandwagon phenomenon in which people make choices based on their perceived popularity a clear outcome of this research is the importance of teaching students to be critical consumers of information as part of individual development and awareness the second two individual values in the model congruence and commitment worked symbiotically to shape student efforts as participants encountered growing awareness they made decisions aligned with those values and pursued subsequent actions examples of action included posting statements organizing events sharing information or voicing agreement while bobby posted information about important causes he deliberately focused on issues individually and prefaced his content to encourage others to engage in this way he demonstrated his commitment while being congruent with his desire to prioritize dialogue maeve demonstrated congruence by seeking out organizations focused on sustainability and environmental responsibility this congruence fueled her commitment as she undertook progressively responsible leadership roles and became more vocal in her personal life for participants online actions complemented inperson efforts this fluidity across spheres reiterates examples of specific campaigns in which social media tactics and inperson action were mutually sustaining to support a holistic strategy of social change social media activism in contrast to critiques of slacktivism participants emphasized that even minor actions such as liking a post are important for social and political change these findings aligned with vies conclusion that changing ones profile picture can show virtual support and counter microaggressions participants viewed the act of liking as a public declaration of their opinions and as a way to enhance the visibility of a cause however several participants also identified the potential of superficial actions to contribute to apathy if not connected to larger meaningful action for undergraduate students it may be important for educators to connect online actions with inperson communities or actions that can foster continued growth involvement in a student organization was one form of meaningful engagement for participants other sources could be cultural centers service learning coursework or volunteer activity in the community the respondents of this study were primarily white women however the usage of social media can vary across different identity groups as marginalized students experience hostile campus climates online spaces that act as sites of resistance and community are particularly important moreover students from marginalized groups may have already experienced the consciousnessraising necessary to develop a social change agenda that makes them more likely to engage in activism here maeve was the only qualitative participant that identified as a student of color she spoke of using social media to engage with the middle eastern community on campus which included a community response to a bias instance her experiences echoed prior literature that examined ways in which students of color used social media to challenge racial oppression educational attainment is a predictor of activism suggesting that those with more coursework are more likely to engage it is also true that juniors and seniors are more likely to assume leadership roles on campus within organizations due to their familiarity with campus culture and their seniority moreover these leadership opportunities come at a time when students are developmentally prepared to engage in difficult decision making in this study seniors like kate and maeve were directly involved in leading their organizations and overseeing organizational social media if students become more involved later in college institutions might benefit from targeted measures of support for these students that integrate past experiences and connect to opportunities postgraduation implications a key goal of this pilot study is to inform future institutional assessment as institutions strive to better promote social justice and diversity empowering students as change agents is a natural extension of institutional missions understanding how to support student leaders in creating social and political change particularly in the prevalence of online environments must be a priority for student affairs administrators as a pilot study findings from this research provide several nuanced understandings first the social change model clearly aligns with student leaders online actions for social and political change and provides a natural framework to gauge students learning and values through leadership roles and activism simply put the theory provides a clear framework with which to ground institutional assessment however a clearer integration of studentlearning outcomes is necessary to create a robust assessment that could be used to enhance student learning at ru the social change model was not widely used by the student activities office without a clearer connection to learningoutcomes and pedagogy in cocurricular spaces efforts to understand student perceptions and behaviors are disconnected from the desired cycle of evaluation decisionmaking communication and planning associated with assessment additionally the social change model encompasses action across the individual group and societal spheres in this study the individual sphere was most salient for student leaders however other institutions have learning outcomes more clearly tied to group and societal impacts practitioners must identify which areas of social change are most targeted through involvement opportunities to create corresponding lines of inquiry second the dynamic nature of social media makes it difficult to create a stagnant assessment as platforms functionality and user interface evolve any inquiry into students social media usage must constantly evolve alongside social media to remain relevant and would benefit from construction with students themselves who are best equipped to explain the digital landscape the centrality of student voice and input is clear here the richest findings are qualitative as participants discussed the nuances of platforms and functionalities that the survey could not capture as such this study reaffirms the importance of using multiple methods of data collection and suggests new possibilities for research methods that more directly center participant agency such as participatory action research the goal of assessment is to guide good practice this pilot study suggests that rather than shying away from the topic of social and political change practitioners can actively help coconstruct environments that illustrate examples of successful student activism moreover conversations about strategies for activism can serve as a teaching tool to help students learn from past examples such dialogue can reframe deficit views on student activism to instead focus on ways that individuals can create forms of social and political change education on activism supports the personal development that occurs amongst students as they engage with social media for example students in this study saw organizational and personal social media accounts linked in many ways thus practitioners may consider exploring these themes with students to help them navigate between their multiple roles the nuance of which grows increasingly complicated as students move into professional jobs and careers intentional engagement can support students in their development as change agents xu q schmierbach m bellur s ash e oeldorfhirsch a kegerise a the effects of friend characteristics on evaluations of an activist group in a social networking context mass communication and society15

social media has shifted the landscape of how individuals create social or political change previous forms of activism relied on inperson methods such as petitioning rallies and letter writing barnhardt 2014 modern technology pushed activism increasingly online as 19 of internet users have posted material about political or social issues smith lehman schlozman verba brady 2009 through online tools individuals spanning vast geographical distances immediately respond to concerns lariviere snider stromberg omeara 2012 the range of available platforms caters to a diverse array of users and functionalities including sharing information gauging interest and building relationships biddix 2010velasquez larose 2015 activists now have multiple tools available for instantaneous widespread impact for college student leaders defined as those holding leadership positions in clubs and organizations on campus social media facilitate attempts to create social or political change through strategies of resistance nakagawa arzubiaga 2014 previous studies focused on social mediasupported activism within higher education to join national protests for racial justice bonilla rosa 2015 to challenge discriminatory government actions lariviere et al 2012 to illuminate microaggressions george mwangi bettencourt malaney 2016 and victim blaming hall 2015 and to respond to oppression and bias senft noble 2013 however less is known about how student leaders choose to engage in social media when pursuing these goals the 20152016 academic year saw student movements against injustices at campuses as diverse as yale university the university of missouri and the university of cincinnati wong green 2016 at research university ru a large public research institution in the northeastern united states student activism addressed issues of racial injustice and institutional investment in fossil fuel companies while students launched events such as sitins and rallies to support these causes little information existed regarding how students viewed such efforts to create social and political change how their approaches were impacted by leadership roles they held on campus and their use of social media for organizing as the field of student affairs considers ways to better support student activism bourke 2017 additional information is needed to inform practice not only is such understanding crucial to promote student development and to address inequity on campus but also to align broader institutional commitments to social justice that vary widely in implementation warikoo 2016 using the framework of the social change model higher education research institute heri 1996komives wagner 2017 this pilot study explores the ways that undergraduate student leaders approached and engaged with social media as a tool specifically i ask the research question how do student leaders use and perceive social media as tools to create social or political change the pilot provides an initial understanding of these concepts that can be used to develop institutional assessments of students experiences working towards creating change on campus such assessments are imperative to inform student affairs administrators in improving leadership

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parents with harmful drinking to better understand the types of support that are provided and the degree of validation in the support received families with parents engaging in harmful alcohol use growing up with a parent engaging in harmful alcohol use is challenging and often has negative consequences for example the likelihood of harmful substance use is approximately 70 higher among offspring of parents with harmful drinking than among other offspring beyond the health risks some offspring of parents with harmful drinking experience a variety of personal and social ramifications such as poor academic performance and psychological distress when parents struggle with alcohol use they tend to neglect family obligations become verbally and physically abusive and withdraw from family relationships these behaviors may create a communication climate that discourages openness prevents the development of close relationships and fosters interpersonal conflict thus the stressor of growing up with a parent with harmful drinking may lead offspring to struggle emotionally and communicate ineffectively in addition the stigmatization and denial that is often associated with parents harmful drinking may make it difficult for offspring to seek support even though support may be an important component of their own recovery as children offspring may not partake in typical childhood behaviors such as inviting friends to their home or involving parents in school activities potentially leading to feelings of marginalization embarrassment and rejection in addition families often avoid discussing parents harmful drinking such that longterm wellbeing is negatively affected for example topic avoidance may lead to loneliness impulsivity stress and relational dissatisfaction examination of support types and person centeredness although supportive resources are available and frequently utilized by adult offspring of parents with harmful alcohol use few studies have examined how adult offspring communicate support to one another we considered the type of support and the person centeredness conveyed within the messages exchanged in online resources to examine offsprings support we used cutrona and suhr social support category system which has been used to identify and quantify forms of supportive communication this system categorizes messages into five distinct types of support informational support consists of messages that are factual in nature and contain advice or knowledge for the recipient emotional support is communication that expresses concern or sympathy esteem support refers to communication meant to bolster and improve ones selfworth or abilities network support is communication that brings the recipient closer to a network of people who have similar ideas or situations finally tangible support is defined as providing physical aid or services to the recipient we also considered the degree of person centeredness in the messages exchanged online by adult offspring of parents with harmful drinking the personcenteredness framework provides a guide for examining the degree of validation in a supportive message by considering high moderate and low levels person centeredness is distinct from other typologies of support because it focuses on how the highly personcentered messages explicitly recognize the others feelings help the person to articulate and elaborate reasons for those feelings and situate those feelings in a broader context moderately personcentered messages acknowledge the recipients feelings by expressing sympathy or distracting attention from the situation low personcentered messages disregard ignore or minimize the recipients feelings although low levels of person centeredness appear dismissive in nature the framework argues that this may be an intended form of support and thus requires consideration notably higher levels of personcentered support messages contribute to personal and relational wellbeing present study this study examined the types of social support that adult children of parents with harmful drinking provide in the context of online support groups focusing on categories of support and description of degree of person centeredness findings from this study will be useful to family members and providers working with adult offspring of parents with harmful drinking as well as to the adult offspring themselves our results will help bring attention to the nature of supportive messages in online forums and highlight forms of support that may better serve the coping needs of adult offspring of parents with harmful drinking method data collection procedure three online forums were selected for analysis and they were selected based on the variation in site setup and structure and because they afforded public access to member posts more specifically the 12stepforumsnet was unique due to the focus on 12 steps soberrecoverycom was unique because it included a moderator and cyberrecoverynet was intended generally to provide connection and support without a 12step focus or moderator all posts were extracted from forums within each website labeled adult children of alcoholics thus site users selfidentified as being adult offspring of a parent with harmful drinking websites all shared a similar purpose in providing an outlet for adult offspring of parents with harmful drinking to share thoughts feelings and questions with others who have had similar experiences although references were occasionally made regarding their own recovery members posts were focused on actively seeking support as a result of being an adult offspring of a parent with harmful drinking all subscribed to an asynchronous platform where messages were not exchanged in real time messages on discussion boards were posted using an anonymous screen name thus persons posting were completely anonymous without any means of identification even so for this study screen names were removed prior to analysis data included discussion strings that consisted of an original post and all replies to the post during a 2month period post activity during the data collection period was as follows 12stepforumsnet had 252 original posts with a mean of 304 replies to a post soberrecoverycom had 410 original posts and m 253 replies and cyberrecoverynet had 151 posts and m 296 replies data analyzed in this study were from replies and not original posts each reply in the discussion string was treated as a unit of analysis with a total of 1644 units of analysis included in the sample institutional review board approval was obtained prior to study initiation coding procedures two independent coders were trained to evaluate all of the messages in terms of the type of support provided and the degree of person centeredness in the message as a starting point each coder read through all of the messages and responses to familiarize himself or herself with the data then the coders were trained to apply each of the coding schemes for the support typology and person centeredness to the data the coding schemes were applied separately such that coders first evaluated all of the messages in the data set in terms of the type of support that was provided and then rated all of the messages in the data set in terms of person centeredness both coders provided ratings for every unit of analysis the data set was divided into five sets each consisting of 20 of the total responses in the data set the coders met with the lead author after completing coding for each set of responses to check for reliability and resolve disagreements disagreements were resolved through discussion and the lead author cast the deciding vote in cases where consensus could not be reached support typology coding we developed a coding scheme based on cutrona and suhrs five support categories of informational emotional esteem network and tangible support following the initial review of the data the coders indicated that the tangible support category was almost nonexistent in the messages which is consistent with findings from other studies that examined online support messages consequently we removed the tangible support category from the coding scheme prior to the assignment of codes many responses did not express concern for the emotion andor feelings of the person providing the original post but instead shifted the discussion to share stories about ones own similar experiences and problems we refer to this strategy as identification the use of identification occurred so frequently that we updated the code list again adding a category of identification the final coding scheme used for the analysis consisted of informational emotional esteem network and identification support we also added a miscellaneous category to be used for posts or responses that contained no supportive content after making adjustments to the coding scheme to fit the data intercoder reliability for the support typology was ƙ 77 person centeredness coding person centeredness was coded in terms of high medium and low levels of person centeredness in the messages intercoder reliability for levels of person centeredness was ƙ 95 results types of social support regarding types of support messages that adult offspring use in the provision of support in online forums on parental alcohol use results indicated that identification was the most frequent type of support followed by emotional support informational support network support and esteem support the miscellaneous category contained 383 of responses identification support in just over one half of responses users provided their own narrative to express how they could relate to or identify with anothers story identification support appeared to be normative in the online community and users frequently expressed gratitude to those who were willing to share their own stories and experiences for example in response to a post about having trust issues one user wrote i also have this issue i even create issues because i think the person really isnt telling me the truth in another situation a user responded to a complaint about not being able to get a handle on finances by saying i know i do this same thing at times i complain about my lack of money how its going to be a quiet one etc … then sometimes i realize and think … hang on … its because you just spent all your money on flights to asia next year finally an individual acknowledged similarities in parental frustration by providing an example from his or her own life i have the same problem my mom is a frickin rn for crying out loud and she lives from paycheck to paycheck always complaining about money emotional support emotional support was used in about one fourth of messages it typically focused on the feelings of another member and considered those feelings by making recommendations and providing encouragement providing emotional support through acknowledgment of anothers feelings can be seen in the following post thank you for sharing it is hard when you have your own situation that you struggle with and you have others that appear to be in a better place with their situation and they complain to you one user expressed sympathy and inquired further about another members feelings that must be a huge burden to carry with you each day are you able to let your husband or even one friend in on what you are feeling in a further example of emotional support a user offered sympathy followed by reassurance regarding a members situation so glad you have jumped in and decided to share so sorry for all you are going through glad you have decided to get out of that situation best of luck to you informational support in the online message boards informational support was demonstrated by recommending a book telling someone about another support site and even posting a howto article one user recommended inspirational readings its hard to live in the now do you have any motivational speaker stuff i started with tony robbins … then read ekart tol power of now there are lots of stuff out there in contrast some users pointed the other forum members to resources from the alcohol use support literature one member suggested the aca adult children of alcoholics big red book and the yellow workbook can be found at this link another user noted today i downloaded an emotional freedom technique manual i am hoping that this will help with this sensation as a way of encouraging others to check out the same resource network support users in the message boards pointed to the online community in the forums themselves as a form of network support beyond online message boards users also encouraged their peers on the message boards to attend other types of support groups to gain help and insight regarding their experiences one member invited another forum user to join a particular online group taking into consideration their level of comfort and anonymity if you ever want a meeting please come to the online meetings one user virtually embraced another in to the online forum community encouraging them to continue working on themselves you are so very welcome here and we are here for you to help you on this journey of self discovery and to even better improve your life after all the work you have done so far esteem support esteem support was typically used to provide encouragement and reinforcement for one another on the message boards in particular users provided esteem support in response to individuals who were selfcritical or putting themselves down in response to a member who said they felt silly about their enthusiasm towards an accomplishment another user wrote you are sooo not being silly that is just fantastic and a wonderful step forward for you well done another example of esteem support is one users words of encouragement regarding anothers note of progress in coping with their lack of confidence it sounds like you are doing great work in a further example a user attempted to lessen the pressure one member felt and reminded them that they were making progress by being present in the online forums try not to be too hard on yourself you are here now where there is help as we say in na narcotics anonymous give yourself a break person centeredness to examine the degree of validation in supportive messages we assessed high moderate and low person centeredness results for person centeredness revealed that 2340 of responses were high in person centeredness 6385 were moderate and 1275 were low high person centeredness online users offered highly personcentered support through encouragement and acceptance for example attention to the needs of the other user and reinforcement to persevere during the holidays i will think of you during the holiday this too shall pass try to just focus on you and what you need as much as possible anyway be nice to yourself and forgive yourself for feeling the way you do it is ok in another message a user attempted to reassure a fellow member about his or her progress and circumstances with his or her partner by taking the time to express empathy this is a very positive development for you and i am glad one of the sad things in a situation like yours is seeing how much someone you love can drag you down financially its a painful dichotomy to see finally a user acknowledged the difficulty of the others situation and made a recommendation for ways in which they could receive additional support this can be so scary and i am sorry i want to help not frighten you more but im sure you want to know realistically what to expect you can write more here if you want and you can send me private messages if you like i will pray for you and your mom today god bless moderate person centeredness about two thirds of responses in the message boards were categorized as moderately person centered the online users acknowledged the problems of other users but addressed them through their own experience rather than direct support for example one user acknowledged anothers parental circumstances and then went on to discuss his or her own experience with his or her father and what impact that had on him or her whatever the case with your father you have been affected by the alcohol just because he wasnt drinking doesnt mean his history didnt influence the type of father he was my dad is now in recoveryyears after i left home hes such a different man yet i find myself still stuck in the aftermath of his alcoholism in another example an individual noted how he or she could relate to anothers family story by then referencing the issues he or she personally experienced growing up with a parent with harmful drinking so i do think we went through much of the same things that other children of alcoholics experienced the secrets the shame and the confusion are much of the same issues teachers having to call our mom to see if it was ok for our dad to pick us up from school … not normal this excerpt exemplifies moderate person centeredness with the user mentioning how he or she can relate to the others story but then changing the topic of conversation to his or her own experience and feelings toward it i can so relate to your story i remember being told children are to be seen and not heard i am still a lost child low person centeredness although low person centeredness was relatively rare in the message boards some users responded in ways that provided minimal support or even challenged the other persons feelings one user curtly posted a response to anothers post that discussed a desire to control or anticipate the actions of others the only thing you have any sort of say in is yourself the rest of it … how i am going to act or think or say … totally out of your control sorry another post confronted a user on his or her personal reflection commenting on his or her ability to work on himself or herself i see you have acknowledged childhood issues you have even worked on it but have you hit your acoa bottom it appears you may have now instead of expressing support for the familial issues experienced around the holidays one user abruptly suggested that another member simply remove himself or herself from the situation well why spend the holidays with people who torment you discussion this study examined the types of support that adult offspring of parents with harmful drinking provided to their peers in online groups and the degree of person centeredness in their messages results indicated that identification was the most frequently used type of support in the discussion boards and that adult offspring typically provided moderately personcentered messages thus these adult offspring mainly used online forums to receive and provide support by expressing sympathy and sharing stories about their own similar experiences and problems as well as solutions they have found that work for them the provision of support one implication of the finding that identification was a main support strategy is that there is a broad sense of understanding and shared experience among adult offspring of harmfullydrinking parents this study gives compelling evidence that there may be features of the adult offsprings experience that make identification a common type of support one explanation is that identification is a minimally sophisticated form of support because it focuses on the self instead of the target thus it might reflect their level of social skill another possibility is that by turning the focus onto themselves adult offspring fulfill a need for attention that was underserved growing up in a home with a parent with harmful drinking adult offspring often referred to a lack of communication in their families growing up and the awkward silences that existed surrounding the parent with harmful drinking perhaps the online forum is seen more as an outlet for expressing their own voice rather than responding to the needs of others similar to that of 12step groups where sharing ones story is an important component of recovery these supportive messages involving identification seem to take the focus off the other person and back to the individual in contrast emotional support messages contained in about one fourth of messages analyzed demonstrate the concern adult offspring of parents with harmful drinking have for one anothers feelings and their ability to communicate empathy emotional support appears contradictory to the more selfinterested supportive responses found in the identification category the number of emotional support messages suggests that adult offspring of parents with harmful drinking believe it is important to include emotional concern when addressing the hardships of others the online forum may be one of the few outlets where adult offspring of parents with harmful drinking receive compassion from those who can relate other family members and friends may not fully understand the problems experienced from growing up in a home where harmful alcohol use is present in addition the discouragement of communication and the frequent conflict often present in families of a parent with harmful drinking may produce an environment where individuals avoid expressing concern and suppress negative feelings therefore the online message boards provide an outlet for adult offspring of parents with harmful drinking to find unity and emotionally support one another informational and network support played a smaller but meaningful role in online support and often functioned together in a shared support goal the online community provides a vital network of support and within these networks adult offspring of parents with harmful drinking are privy to a vast amount of informational resources including experiences insights and recommendations more needs to be done to inform individuals who are not participating in these online networks about the potential support resources available to them through this medium much of the esteem support was used in response to selfcriticism which is consistent with earlier findings regarding selfesteem issues among many adult offspring of parents with harmful drinking research suggests that selfdeprecation is often a result of growing up in a home with a parent with harmful drinking and that low selfesteem is a common characteristic of offspring given that some adult offspring of parents with harmful drinking struggle with selfesteem finding reliable sources of esteem support is important for their wellbeing that this type of support was the least frequent to occur in the message boards suggests that online support groups may not fulfill this need for adult offspring of parents with harmful drinking increasing esteem support is an important strategy for helping adult offspring of parents with harmful drinking feel confident about themselves and their relationships thus other sources of esteem support should be sought outside of online support groups or more effort should be made to introduce esteem support to existing online groups one way to do this is to have moderators emphasize the importance of selfesteem through periodical posts moderators may do this using quotes or bringing in literature that aids in improving or reflecting on selfesteem alternatively moderators could integrate monthly posts that encourage discussion of the ways in which online members work to enhance their own selfesteem as a form of experiential learning that may benefit all members for person centeredness moderate responses appeared most frequently in the online forums that is offspring of parents with harmful drinking acknowledged and sympathized with others feelings but limited their supportive messages to socially normative overtures of care and tended to focus on how the others dilemma related to their own experiences the higher frequency of moderate personcentered messages may stem from features of the online environment and from adult offsprings communication skills it may be difficult to provide highly personcentered support in anonymous internet message boards because users lack sufficient information about others to construct messages that reflect personal understanding consequently individuals rely on norms for socially appropriate messages of support in addition offspring may lack sufficient communication skills to provide more sophisticated support as a result of their upbringing in a family affected by alcohol use additional research is needed to assess offsprings ability to provide effective and appropriate support in various facetoface and anonymous contexts as well as the possible intersection between identification support and moderate person centeredness in this regard perhaps supportive messages that are moderately person centered also demonstrate identification support researchers should examine the way these support message frameworks may be conceptualized together in an effort to better understand how individuals exchange support generally studies have found support giving and support seeking to be positively related one possible way of examining the reciprocal effect of support in this context is through sequential analysis to see how support requests or original posts are related to support provided the relatively limited use of low personcenteredness messages in the online forums may be due to the fact that such messages may be perceived as hostile and inappropriate similarly high person centeredness may be less apparent online because individuals lack personal knowledge of other users that would allow them to construct more sophisticated messages additionally the weaktie relationships among forum members may reduce the motivation to invest effort in forming more complex support messages as noted earlier families laden with conflict may make it difficult for children to develop socially appropriate communication skills thus some adult offspring of parents with harmful drinking may lack the skill necessary to construct more effective messages strengths limitations and future directions this study was characterized by several strengths we had a relatively large sample size of messages coded for supportiveness and the evaluation of supportiveness was theoretically grounded the study added to the existing support typology and extended its applicability to online contexts by considering the role of identification as a support technique this study also provides guidance for families of parents with harmful drinking and health providers working with these families given the benefits of high person centeredness and the lack of high person centeredness present in the data family members and practitioners could try to enact more high personcenteredness messages when offering support to adult offspring similarly the existence of disparaging or selfdeprecating messages in the online forums point to the importance of bolstering adult offspring selfesteem to promote more resilience and in turn the ability to cope this study also highlights the benefits of online forums geared toward adult offspring based on the results of this study the online setting appears to be a viable resource for conversing with those who share in experiences as well as a place to learn about alternative sources of support via the online member network a study limitation was the inability to assess how users perceived the support they received although coders evaluated the degree of person centeredness in the messages the extent to which users found those messages to be supportive remains unknown in addition given the nature of the data we were unable to examine direct effects of how growing up with an parent using alcohol may have influenced adult offsprings ability to communicate support another limitation was the anonymous nature of the data which made it impossible to draw conclusions about differences in support due to gender race ethnicity age or other personal characteristics this also made it impossible to differentiate posts of individuals based on parents alcoholrelated diagnoses and severity findings from this study point to fruitful avenues for future research on the provision of support and the communication behaviors of adult offspring of parents with harmful drinking one is to further investigate the use of identification as a method of support of particular interest is whether identification is unique to this population the online context or is also used in facetoface interactions thus future research should examine the phenomenon of identification as a support category in a variety of contexts furthermore research should consider the consequences to the support seeker of receiving identification messages in response to requests for support additional research is also needed to explore the extent to which online support groups for adult offspring provide information and support that facilitate coping with a drinking parent as noted earlier future research that examines the relationship between support seeking and support giving through methods such as sequential analysis would provide depth to the experience of support among adult offspring of parents with harmful drinking furthermore longitudinal investigations of adult offspring of parents with harmful drinking who rely on online forums for support would provide useful insights into the instrumentality of online support groups for bolstering individual and relational outcomes in sum this study suggests that adult offspring of drinking parents use online forums to receive and give support as well as offer one another workable solutions to life problems however findings also suggest that most messages exchanged were not highly person centered and those seeking greater validation of experiences are likely to need additional sources of support

the authors categorized communication strategies employed to exchange social support type and person centeredness in three online forums about parents with harmful drinking data included discussion postreplies over 2 months n 1644 units of analysis support type categories were identification emotional informational network and esteem for person centeredness most messages were moderate expressed sympathy provided distraction followed by high helped with feelings and then low minimized feelings adult offspring of parents with harmful drinking predominantly communicate selfinterested forms of support in online forums based on principles of supportive communication esteem support and high person centeredness may enhance social support in these settingssocial support online adult offspring harmful alcohol use communication adults who grew up in homes in which a parent engaged in harmful alcohol use exhibit an increase in maladjustment straussner fewell 2011 and are at risk for low selfesteem anxiety disorders and depression rangarajan kelly 2006 there are multiple online groups for adult offspring who seek supportive resources however the conditions of growing up in a home with a parent with harmful drinking 1 may make it difficult for adult offspring to communicate about feelings and concerns and in turn receive adequate support thus the goal of this study was to examine online support boards for adult offspring of contact marie c haverfield

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introduction dien bien is a mountainous border province in the northwest region of vietnam sharing a border with laos in the west and south china in the north besides dien bien is also connected to the red river delta of vietnam and neighboring provinces by national highways 6 and 12 and recently there has been an increase in the frequency and intensity of extreme weather events including heavy rainfall and associated flooding these phenomena not only affect peoples lives but also cause serious damage to farmers agricultural production in the period 20172021 dien bien recorded a clear change in the rural economic structure of the nonagricultural sector the economic structure of the province has shifted towards increasing the proportion of industries and services gradually reducing the agriculture forestry and fishery sectors according to data from the dien bien statistical yearbook 2021 industry and construction increased by 85 and service industries rose by 599 over the period of five years from 2017 to 2021 consequently the annual economic growth rate of the province has been quite good compared to other provinces with the same conditions the growth rate of gross regional domestic product reached 605 over the period of 20172021 increasing by 601 in 2021 compared to 2020 the economic structure of the province has shifted in a positive direction increasing the proportion of industries and services and gradually reducing the agriculture forestry and fishery sectors looking at the past nonagricultural activity in rural areas has been the concern of many researchers around the world according to lanjouw and lanjouw nonagricultural activities in rural areas are incomegenerating activities in rural areas that are not part of agricultural activity in 2003 davis argued that nonagricultural economic activities are activities that are not part of the original types of agricultural activities such as farming animal husbandry fishing and hunting in other words nonagricultural economic activities in rural areas are incomegenerating activities that do not fall under the original agricultural category either through waged work or in selfemployment another concept introduced by abdulaziz et al was that nonagricultural activities are all economic activities such as manufacturing service and mining and extractives except agriculture livestock fishing and hunting this definition comes true regarding the area and types of nonagricultural activity nonagricultural activity includes activities that do not directly relate to traditional agriculture in rural areas and access local resources to provide rural people with a good source of income and employment in vietnam nonagricultural activity has become the goal of vietnams rural modernization and industrialization process nonagricultural economic development plays an important role in rural modernization restructuring the rural economy in a positive way and improving the quality of life of rural people therefore the purpose of this paper is to answer two research questions rq1 what factors affect the decision of rural households to participate in nonagricultural activities in dien bien province rq2 which solutions are proposed to promote nonagricultural activities of rural households in dien bien province literature review and methodology literature review this section focuses on two aspects to form the proposed research model the first focuses on the theory of pull and push factors involved in the nonagricultural activity of farm households the second focuses on the empirical evidence of the factors affecting farmers decisions to participate in nonagricultural activities this study relies on the theory of pull and push factors proposed by reardon t and davis and pearce reardon offers the following push factors population growth increased scarcity of productive land reduced access to fertile soil decreased soil fertility and productivity decreased basic natural resources decreased revenue for agriculture increased demand for money in life events and shocks occurring lack of access to input markets for agricultural production lack of rural financial markets in addition he suggested pull factors such as higher revenues of nonagricultural workers higher revenues when investing in the nonagricultural sector lower risks of the nonagricultural sector compared to the agricultural sector generating cash to meet the spending needs of families and more opportunities to invest in short the pull factor presents the attractiveness of the nonagricultural sector to farmers the push factor involves the pressure or restrictions of the agricultural sector that force farmers to seek other income if they want to improve their living conditions davis and pearce in 2000 when analyzing the characteristics of the rural nonfarm economy also systematized the factors affecting the decision of rural households to participate in nonagricultural activities as follows labor yields in nonagricultural business are high yields engaged in nonagricultural business are high the risk of nonagricultural business is lower than that of agricultural activity provide cash to meet the needs of households economic opportunities often associated with social advantage can be found in urban centers and outside of the region or country the appeal of city life especially for young people source davis and pearce the participation of farmers in nonagricultural activities is due to both the pull and push factors however pull and push relations are only factors that encourage the participation of households in fact participation in nonagricultural activities also depends on the ability factors of farmers as shown in previous studies kanwal et al have shown that low productivity and income from pakistani agriculture have led rural people to seek alternative livelihoods especially nonagricultural employment similarly dontsopnguezet et al also pointed out that the trend of rural households in south kivu congo is to include nonagricultural activities in survival strategies and diversify sources of income higher income from nonagricultural activities is the main pull factor influencing rural households decisions to join in nonagricultural activities in addition ellis ellis andtassew argued that one of the motivations for diversifying income sources into nonagricultural activities is managing risks associated with agricultural production imai et al also showed that diversifying household activities into the nonagricultural sector will reduce future risks and shocks such as weather shocks diseases and macroeconomic downturns another factor that plays an important role in farmers decisions to participate in nonagricultural activities is the gender of the head of the household the gender of householders also has a significant impact on nonfarm participation with female householders more likely to engage in selfemployed work than men in contrast male householders are more likely to engage in employed activities kung and lee through the probit model also showed that education is an important factor in accessing nonagricultural employment this result is similar to other studies when explaining that education level has a positive impact on farmers decisions to participate in nonagricultural activities the higher the education level the higher the probability of participating in nonagricultural activities the area of farming land is one of the factors that strongly affects the decision of rural households to diversify production activities the larger the area of farming land the greater the impact on the decision of farmers to participate in nonagricultural activities imai et al showed that the more land a household owns the higher the probability of nonfarm participation in addition the larger the area of farming land the higher the income from nonagricultural activities in contrast some researchers suggested that the more the area of farming land per capita the lower the likelihood of receiving nonagricultural jobs access to information is also a key factor in the decision of rural households to participate in production activities households in different areas are likely to engage in different nonagricultural activities due to differences in socioeconomic conditions dary and kuunibe through the logit model showed that the probability of participating in nonfarm activities increases when an individual belongs to an organization organizations will be the place to provide reliable information such as microcredit markets agricultural extension etc to members oseni and winters studied the relationship between nonagricultural participation and input costs for agricultural production by farmers the results showed that the high cost of agricultural activities has pushed farmers to participate in nonagricultural activities to loosen credit constraints this is consistent with the study of cuong et al that found income from agriculture has not made a difference in investment in cultivation and investment items for livestock such as breeds feed and veterinary medicines analysis framework based on the theory of pull and push factors to participate in nonagricultural activities of rural households as well as an empirical research overview of factors affecting farmers decisions to participate in nonagricultural activities the proposed factors are presented as follows econometric model in this research the authors estimate the factors affecting the decision of rural households to participate in nonagricultural activities in dien bien province this implies that the response variable is whether to participate in for the binary or dichotomous dependent variable the logit or probit model is chosen to do regression analysis because logit and probit regression models are the frequently used statistical methods for predicting the binary or dichotomous dependent variable this means that the response of interest can take up only two values 0 or 1 however the key difference between the logit and probit models is that the logit model is used to model the odds of success of an event as a function of independent variables while the probit model is used to determine the likelihood that an item or event will fall into one of a range of categories by estimating the probability that observation with specific features will belong to a particular category therefore in this study the authors use the logistic regression analysis approach to estimate the factors affecting the decision of rural households to participate in nonagricultural activities in dien bien province the study is based on the logit model suppose the linear probability model 𝑦 𝛽𝑥 𝜀 where i y equal 1 if rural households in dien bien province decided to participate in nonagricultural activities otherwise equal 0 are the factors affecting households decision making is the coefficient of the variables and is the random error in this research the authors analyzed the probability of each household 𝑖 randomly drawn from the population and expressed as follows 𝑃𝑟 exp 1 exp the probability that households decided to participate in nonagricultural activities is 𝑃 𝑃𝑟 𝑃𝑟 exp 1 exp 1 1 exp the probability for undecided households to engage in nonagricultural activity is 1 𝑃 1 1 exp therefore 𝑃 1 𝑃 1 exp 1 exp 𝑒 natural logarithm l ln 𝑃 1 𝑃 𝑦 this equation can be replaced with the following formula l ln the statistical results showed that although the surveyed households said that the head of household is predominantly female the average value of the gender of householder participating in nonagricultural activities is lower than that of not participating in nonagricultural activities this means that households with male householders tend to engage in nonagricultural activities the average years of schooling of the household head is only 4557692 years which means that primary school has not been completed limited educational attainment is i y i x n i 1  i  very common in rural areas in dien bien province the relationship between participating and nonparticipating groups also showed that there was no clear difference between the education levels of householders of the two groups which were low the average area of farming land of the participating group is significantly lower than that of the nonparticipating group in the group of participating households the average area of farming land is 7102222 m2 while this figure in the nonparticipating group is 8311807 m2 however the average nonfarming income of participating households showed a significant outperformance compared to nonagricultural households participating households recorded an average income of vnd 2697781 million nearly 5 times higher than the sample mean participation in nonagricultural activities brings high economic value to rural households in dien bien therefore there is also a difference in the total expenditure on agriculture between participating and nonparticipating households in nonagricultural activities nonagricultural households have higher spending on agricultural production with an average expenditure of vnd 428646 million the results showed that 8889 of households participated chiefly in manufacturing and processing industries this is the sector that attracts the greatest participation for households in the rural area of dien bien of which 8254 are engaged in producing beverages source authors calculations logit regression results the estimated coefficients of parameters and the marginal effects in the logit model are summarized the result shows that except for education measured by the years of schooling variable the remaining variables are significant at the 10 5 and 1 levels it is also revealed from the findings that access to information has the greatest impact on households decisions to participate in nonagricultural activities when one more household has access to information the total number of households participating in nonagricultural activities will decrease by 2807 holding other variables unchanged this result is inconsistent with the previous studies it can easily be explained that the sources of information farmers have access to are mainly agricultural development organizations and relatives friends and neighbors the information that agricultural development organizations provide is mainly agricultural extension information and access to credit for agricultural production activities etc in addition the speed of information transmission of relatives friends and neighbors is very fast and there is great trust in rural society therefore households will be hesitant in deciding to participate in nonagricultural activities when accessing more information about agricultural production besides all other variables are held constant if the head of household is female the probability of participating in nonagricultural activities is lower than that of the male householder a possible explanation is that households are mainly involved in the manufacturing and processing industries which require more male labor on the contrary women tend to be more involved in wholesale and retail jobs furthermore if households have a large area of farming land the trend to engage in nonagricultural activities decreases the reason is that increasing the size of farming land specializing in agricultural production facilitates investment in the application of science and technology according to concentrated production areas increasing productivity product quality and increasing income for people furthermore the higher the nonfarming income the higher the probability of households deciding to participate in nonagricultural activities in contrast an increase in the total costs for agriculture increases the possibility to participate in nonagricultural activities when the input costs for agriculture increase it will create an additional financial burden on the agricultural production activities of farmers therefore households will seek diversification in production to increase incomes and improve the quality of life similarly the greater the losses from agricultural production the less interested farmers are in agriculture promoting participation in nonagricultural activities it was also indicated that loss by risks also has a positive effect on households decisions to engage in nonagricultural activities this result is consistent with the research of reardon and davis and pearce that participation in the nonagricultural sector minimizes uncertainties compared to the agricultural sector in fact the loss by risks discussed include natural risks and economic risks in recent years climate change has strongly impacted agricultural production across the country the geographical conditions of dien bien province are subject to many natural risks with natural disasters such as thunderstorms pipe floods flash floods landslides and droughts appearing frequently and continuously with greater intensity recently pandemics have become more and more complicated and difficult to control such as pests destroying crops avian influenza and the covid19 pandemic all have severely affected productivity and quality and caused restrictions on the production and trade of agricultural products it can be said that if natural risks are increasingly occurring with greater frequency and high intensity it is difficult for people to cope both materially and mentally when only maintaining agricultural activities the results are similar with the studies of ellis ellis ellis kijima et al demie and zeray imai et al for nonnatural risks such as economic risks agricultural products depreciate in the market the price of input materials for agricultural activities fluctuates and the economic efficiency from agricultural activities is not high these are also the causes that seriously affect agricultural activities therefore the smaller the losses from nonagricultural production the less interested farmers are in agriculture pulling farmers towards participation in nonagricultural activities on the other hand the years of schooling variable is not significant in the logit regression model it can be explained that the education level of farm householders in dien bien province is relatively low at a mean of 46 years of schooling also there is not a big disparity between participation and nonparticipation groups in nonagricultural activities this implies that education has not played an important part in the decision to engage in rural nonagriculture in dien bien province 4 some solutions to promote nonagricultural activities in dien bien province orientation of dien bien province based on the inherent advantages and potentials of the province dien bien has determined the general objective by 2025 is to bring dien bien province to develop fast and sustainably therefore the province is focusing on exploiting the potential and advantages of the locality for economic development in particular the province has the goal of turning tourism into a spearhead economic sector with three main pillars spiritualhistorical tourism cultural tourism associated with experiences and tourism of resort and recreational sports in addition in order to promote the development of rural areas in dien bien province the provincial peoples committee issued decision no 375qdubnd dated 2332021 on the approval the industrial promotion program of dien bien over the period 20212025 the province has listed the following objectives restructuring the rural economy towards industrialization and modernization based on mobilizing and effectively using all resources supporting the development of typical industrial products encouraging the transfer and application of scientific and technological advances towards sustainable development creating favorable conditions for all individuals and organizations to invest in sustainable industrial development from that combined with the research results the authors propose some solutions to promote nonagricultural activities in dien bien rural areas as follows 42 solutions for authorities firstly the practice has shown that the geographical location creates favorable conditions for dien bien to develop an interprovincial economy as well as the border gate economy therefore dien biens identification and mobilization of all investment resources for infrastructure are necessary to promote rural economic development good infrastructure not only improves production capacity but also helps to cope with natural disasters at the same time it helps the province attract foreign investment capital besides information and communication infrastructure also need to be focused on because the source of information that rural households in dien bien have access to is mainly from agricultural development organizations and relatives friends and neighbors the role of the internet and newspapers needs to be promoted so that people can promptly update information from the central to local levels especially information on promoting nonagricultural economic development such as industrial promotion information secondly the capacity of managers at all authorities should be enhanced to meet industrial promotion policy requirements the teams working on industrial promotion and the owners of rural industrial establishments need to strengthen their professional expertise through training and learning from the experiences of other localities such as bac ninh in the implementation and management of industrial promotion in addition managers must be those who master guidelines and policies know how to organize implementation and are dedicated and enthusiastic they need to have a direct understanding of the local situation grasping the psychology and desire of local people to apply the policy most appropriately and effectively this is a key factor in the case of the low education level of rural people thirdly there should be strengthening and renewing communication on diversifying production and business activities and nonagricultural business employment in order to change farmers perceptions helping them understand the role of nonagricultural activities in rural areas recognizing the importance of rural nonagricultural activities people will actively participate in nonagricultural activities during idle farming periods promoting community participation and development furthermore it is extremely necessary to universalize education for all people enabling them to know reading and writing through shortterm classes deployed weekly at local facilities fourthly coordination with other organizations such as agricultural development organizations should be strengthened in order to implement industrial promotion programs quickly fifthly there should be quick implementation of the application of scientific and technological advances to production in rural areas the government will be the bridge to promote this activity in the fastest way the result will be both increases in production value and achievement of the sustainable development goals of the whole province solutions for local people an important concern is that households must create conditions for their children to have the opportunity to go to school the education of dien bien householders does not make a difference in the decision to participate in nonagricultural activities but a high level of education will make a difference in nonagricultural business results moreover households must also strengthen other soft skills to meet the quality requirements of tourism human resources in the context of internationalization and deep integration another problem is that households should access financial sources and external resources to expand their own production the investment of households in nonagricultural activities is relatively large mainly selfproduction and business activities in processing and manufacturing however investment capital can create a huge difference among households which means that the scale of production is uneven between households creating uneven development conclusion this paper investigates the factors affecting the decision of rural households to participate in nonagricultural activities in dien bien province using a dataset of 312 households in dien bien province the authors find that the decision to engage in nonagricultural activities in rural areas of dien bien province depends on the gender of householders nonfarming income and the loss by risks the area of farming land access to information and the total costs for agriculture the results of the logit model reveal that education is not a significant variable while it is an important factor in other studies hence based on the above results as well as the orientation of dien bien province the authors suggest some important solutions the issues to be solved belong to two actors including authorities and local people households themselves must exploit and take advantage of available potentials along with the support of the state and local authorities toimprove their livelihoods as well as contribute to promoting the overall development of the locality

the paper examines factors affecting the decision of rural households to participate in nonagricultural activities in dien bien province through the logit model using the vietnam access to resources household survey 2016 by the general statistics office of vietnam the results indicated that the decision to participate in nonagricultural activities is driven by both push and pull factors but there is also an indication of an ability factor at work access to the information variable has the greatest influence on the decision of households to participate or not moreover education is not significant and has no influence on the decision to engage in nonagricultural activities of households in rural area of dien bien province based on the findings as well as the rural development orientation of dien bien province the author proposes some solutions to promote rural nonagricultural economic development rural nonagricultural development policies should attend to promotion of the education level of rural households and create favorable conditions for households to access resources

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introduction education is considered a way out of the vicious circle of poverty it helps in determining the productivity level of an individual highly educated people tend to be more productive in comparison to their counterparts the pioneering studies focusing on human capital identify investment in education as the major factor of higher production an investment in an additional year of schooling constructs human capital and causes an increase in efficiency therefore an additional year in school results in increased income for an individual similarly differences in the training of labor force participants are the major factor of differences in personal income distribution we find many examples in our daily lives supporting this notion for instance the salary of a college lecturer with the same working hours is much higher than that of a primary school teacher this difference is the result of the difference in the qualifications of the two workers the data from the pakistan social and living standard made free and all the private schools at the primary middle secondary higher secondary and college levels were nationalized the sixth five year plan emphasized increasing enrolment at the secondary level and providing technical education the seventh fiveyear plan reversed the policy of nationalization of schools and the sector was opened to private schools except for the second fiveyear plan the majority of plans could not achieve their targets in 2000 the united nations made education a target in its millennium development declaration and envisioned achieving primary education for all children until 2015 however pakistan could not achieve the millennium development goals in 2015 these unachieved goals have become an integral part of the sustainable development goals achievable until 2030 furthermore the target of primary education has been revised and the sustainable development goals aim at achieving secondary education for all children until 2030 owing to this importance secondary education was made compulsory in the constitution of pakistan in 2010 under the law the state is obligated to provide free education to all children therefore the government establishes public schools at the primary middle and secondary levels on the other hand owing to the high demand for schooling the private sector also realizes the opportunity to provide services and earn profit in the education sector the situation of enrolment supply of schools and teachers at different education levels in pakistan is provided in table 2 enrolment the number of schools and the number of teachers are increasing in pakistan primary enrolment during 202122 has increased by 38 at the middle level by 55 and at the secondary level by 73 as compared to enrolment in 201011 access to school significantly affects the decision to enroll female children at the primary level in rural areas of pakistan the provision of primary schools in rural areas significantly increases the likelihood of female children enrolling in school however the addition of a primary school in a village that already has a public school does not have a significant impact on enrolment similarly the number of schools and teachers has increased over the past decade although the number of teachers at secondary level is higher than the number of teachers at primary level but the enrolment at secondary level has remained low one of the reasons for low enrollment is a lower willingness to pay for education in rural areas children from poor families in rural areas face higher opportunity cost s and their families tend to have a low willingness to pay for education on the other hand in urban areas the income of household the heads occupation the heads education the periodicity of the heads earnings and households dominated by a men play an important role in a childs schooling despite all the efforts to increase the number of schools the universal education level the number of teachers and the training of teachers the performance of pakistan in educational indicators is not promising furthermore the completion rate at the primary middle and secondary levels stood at 67 47 and 23 respectively this also indicates that the secondary level has remained neglected at the national level these statistics reveal that despite being a signatory to the sdgs pakistan lags far behind in achieving quality secondary education for all children private schools are considered to provide quality education therefore people in urban areas prefer to enroll their children in private schools the increase in demand for private schooling in pakistan after 2000 is leading to higher competition among private schools this increase in competition calls for analyzing the factors involved in a households decision to educate its children many studies including safarzyńska and idrees and khan have analyzed the socioeconomic determinants of demand for education they investigated the overall impact of income on demand for education however the response of households to different factors varies according to their income group for example sending a child to a school at distance may not be a problem for a rich family due to the availability of transportation at the same time it may be an obstacle for poor families therefore it is important to know how different factors affect the decisions of households from different income groups additionally such analysis is important in determining whether secondary education is considered a normal commodity or an inferior commodity in this context it is important for policymakers as well as educational institutions to know the socioeconomic factors affecting the decision of households to enroll children in school from different income levels the present study attempts to identify the socioeconomic factors involved at the household level in determining a households decision to enroll children in secondary school similarly the study also attempts to identify whether secondary education is considered a normal commodity or an inferior commodity among pakistanis for this purpose we define six categories of income and consider it a categorical variable in our estimation furthermore pakistans cultural values and behavior of people align with those of neighboring countries like india bangladesh sri lanka nepal and bhutan so the results of pakistan can be generalized to these countries which have a large proportion of the world population this study will also be helpful for educational institutions to increase enrolment at the secondary level the study proceeds as follows after the introduction literature review is provided in section 2 the research focus and methodology are discussed in section 3 section 4 presents estimation results and discussion section 5 finally concludes the study literature review the pioneering studies focusing on human capital identify investment in education as the major factor of higher production mincer identified differences in training of labor force participants the major factor of differences in personal income distribution becker considered schooling and on job training the main factors of determining the wage of an individual furthermore becker accounted the impact of varying cultures and political regimes and showed that education and skills positively affect the earnings these studies explored the role of education in economic growth hence the developing countries started formulating policies to increase the education level during 1970s these policies required understanding the determinants of social demand for education psacharopoulos utilized the individual data of lower secondary students and showed that socioeconomic characteristics such as age family income school grades and school type have a significant impact on the decision to enroll in upper secondary education kodde showed that demand for education increases with increase in risk for future earnings stiglitz tried to determine the equilibrium level of education under private public and mixed systems by considering education a public consumption commodity private consumption commodity private capital he found that equilibrium level did not occur on efficient provision level in public provision the education was found to be undersupplied and in private system there were excessive expenditures on education bishop showed that expanding student aid program relaxing admission policies and increasing the number of public colleges in areas where they did not previously exist could increase the enrollment khattak khan khan and tariq attempted to identify the household characteristics affecting the demand for higher education in the province of khyber pakhtunkhwa pakistan they found that age of person being married access to institutions parental education awareness and family income are the major determinants of higher education similarly hamid analyzed the determinants of schooling in urban areas of pakistan she showed that income of household heads occupation heads education periodicity of heads earning and household dominated by a male play important role in childs schooling furthermore economically constrained parents from pakistan and india tend to favor male education because male children live with their parents and participate in family income after completing their education whereas females are expected to leave the house of parents after marriage and dont contribute into the family income of their parents lioyd et al found that provision of a public school in village significantly affects households decision to enroll female child in primary school however addition of a primary school in a village that already has a public school does not have significant impact on enrolment khan and ali showed the existence of gender parity in schooling of children the education of household head positively aff ects the schooling decision of children however mothers education has higher positive impact on schooling of children children from larger families are more likely to attend school but the sibling size decreases the chances of attending school burney and irfan studied the impact of parental characteristics and supply of schools on enrolment of children in pakistan they showed that household total income parental education and land ownership have a positive impact on households decision to invest in human capital idrees and khan provided empirical analysis of socioeconomic factors in demand for education at household level they considered a categorical dependent variable comprising the ratio of enrolment at household level they showed that heads education educated earners and male proportion in household have a positiv e impact on demand for education at household level baluch and shahid attempted to analyze the determinants of enrollment in primary school in lahore pakistan the logit estimates of primary data showed that family size expenditure on education dwelling ownership literacy ration and dependency ration of household have positiv e effect on the decision to enroll child in primary they showed that access to school did not play significant effect on childs attending the school zafar and ahmad attempted to identify the determinants of educational attainment for rural girls of jhang pakistan they showed that parental higher education distance from school residential status of household gender biased behavior of head and attitude of head towards female education play positive effect in attainment of female education hashmi © 2024 aess publications all rights reserved lodhi tsegai and gerber analyzed the determinants of childs participation in education and different activities such as secular schooling religious education child labor a combination of child labor and secular schooling and inactivity they showed that parental perception significantly affects the engagement of child in secular schooling religious education and child labor furthermore female children were more likely to engage in child labor and low probability to engage in secular schooling in rural areas similarly parents were more likely to send male children to school as compared to female children safarzyńska examined the socioeconomic determinants of demand for private tutoring in poland by utilizing samples of secondary school students from national survey data of pisa she found that decision of parents to demand for private tutoring is sensitive to students gender liu and bray analyzed the determinants of demand for private tutoring in china they utilized nationa l survey data of china family panel studies and employed hurdle model to examine the factors shaping a households decision they found that there arent significant gender differences in the demand for private tutoring household income urban region parental education and expected future education level of student have significant positive effect different studies used various methods to measure the demand idrees and khan used a different measure as compared to earlier studies by taking the proportion of school going members to total number of school age members they analyzed the socioeconomic factors determining the demand for schooling at household level by taking the percentage of members enrolled in school or have attained a specific schooling they categorized households into five categories depending on the percentage of children having demand for education and employed multinomial logit estimation however modeling of demand in this manner has limited practical implication in which a household may choose between selecting a specific proportion of its school age member to get education although gender bias may exist in a household when it comes to educating its children the literature has mainly focused on overall effect of household income on the decision to enroll children at school the decision to enroll children at secondary school by households of different income groups has remained neglected largely clearly there is a significant difference for demand of secondary schooling by poor and rich households therefore this study will analyze the factors affecting demand for secondary school for households from different income groups research focus and methodology research question the present study measures the demand for secondary schooling by observing the revealed behavior of households if a household had enrolled its secondary schoolgoingage member into secondary school or heshe had attained secondary schooling then the household is considered to have demand for secondary schooling this study addresses two questions 1 do households consider secondary schooling as a normal commodity 2 how does female headship affect a households demand for secondary schooling 3 how these characteristics have different effect across income groups we focus on demographic characteristics as well as supply side characteristics data source in this study the data of pakistan social and living standard measurement survey 201920 has been utilized pslm has been designed to provide information on social and economic indicators at provincial and district levels pslm was used for the monitoring of six out of sixteen targets and 15 out of 17 indicators of the millennium development goals adopted by pakistan however after the introduction of sustainable development goals by the united nations the pslm is being used for monitoring the sdgs pslm covers all urban and rural areas of pakistan it provides information on education health access to basic services and income and expenditure at the individual as well as household level it had adopted twostage stratified sample design for the collection of data the survey covered 876355 individuals out of 160654 households from across pakistan the survey took villages and enumeration blocks in urban as well as rural areas as primary sampling units furthermore the probability proportional to size method was used for selection of sample psus from strata the survey considered households in the sample psus as secondary sampling units further 16 households from rural psus and 12 households from urban psus were selected using systematic sampling technique with a random start the collection of data for pslm 2019 20 started in october 2019 and was completed in march 2020 the current study is an attempt to explore the role of socioeconomic factors in shaping the decision of households to enroll children in secondary school specifically the effect of households region heads education mothers education average education of elders distance from school ge nder of head age of head proportion of male members in household and income group of households will be analyzed further the study divides the households according to the income group to which they belong then we analyze the effect of these variables to better understand their impact on each income category for the said purpose a total of 76695 households with at least one member of age between 13 and 20 years were selected from the pslm 201920 survey this age bracket was identified as secondary school age after analyzing the pslm data the data revealed that around 974 of children who were enrolled in secondary school belonged to this age bracket furthermore the household was considered to have demand for secondary if it had enrolled at least one member of target age group in secondary class durrenayab has estimated middle income class for pakistan current study utilizes the income classes defined in the said study average exchange rate for the period of october 2019 to march 2020 when the field enumeration of pslm was carried out was utilized for conversion of us into pak rupee the income groups from lower income to high income have been classified as in table 3 estimation this study depends upon the social demand model which is based on individual demand for education this approach emphasizes more on demographic projections than any other model therefore we employ different demographic variables and analyze their impact on demand for secondary schooling to answer our research questions we employ logit estimation as our dependent variable takes the form of dichotomous variable having values of 0 and 1 following econometric model has been identified involving household as well as community level variables 𝑌 𝑖 𝛽 0 𝛽 𝑖 𝑋 𝑖 𝜇 𝑖 where 𝑌 𝑖 is the vector of dummy dependent variable with 𝑌 𝑖 1 if household demands for secondary schooling 𝜇 𝑖 error term our dependent variable is a dummy and this type of specification for dependent variable poses two major problems first predicted values of the dependent variable through ols which represent the probability of a household to demand education may exceed the probability limit of 0 1 thus leaving the meaningless interpretation of the predicted values second due to the dichotomous values of the dependent variable variancecovariance matrix of the error term may no longer remain an identity matrix thus creating a problem of heteroscedasticity to handle these problems we employ the maximum likelihood estimation method to estimate the parameters involved as the maximum likelihood ensures the bounded values of probability to lie in the 01 range it also ensures the asymptotic efficiency and consistency of the parameters therefore following pohlmann and leitner we transform our model into logit specification so our dependent variable in logit specification takes the form of equation 2 l i ln 𝛽 0 𝛽 𝑖 𝑋 𝑖 𝜇 𝑖 here 𝑃 𝑖 can be represented as follows 𝑃 𝑖 𝐸 1 1𝑒 the term in parenthesis in equation 2 is simply log of odds ratio in favor of secondary or the ratio of probability of having demand for secondary to the probability that it will not have demand the variable 𝑋 𝑖 in equation 3 is the vector of all independent variables and the coefficient 𝛽 𝑖 is the vector of all independent variables involved in equation 2 but in our analyses we are interested in finding out the marginal effect of any explanatory variable this marginal effect can be computed by differentiating the equation 3 with respect to𝑋 𝑖 𝜕𝑃 𝜕𝑋 𝑖 𝛽 𝑖 𝑃 here 𝛽 𝑖 is the vector for maximum likelihood estimates of explanatory variables through logit estimation for model evaluation the study will first check the overall significance of each model hosmer and lemshow has suggested likelihood ratio test for testing significance of multiple logistic regression models the test can be performed through equation 5 𝐺 2 ln the statistic g has a chisquare distribution the pvalue for the test can be given by 𝑃 𝜒 2 𝐺 𝑃 the null hypothesis in lr test assumes that all coefficients are equal to zero the rejection of null hypothesis will show that at least one coefficient of the model is nonzero furthermore in order to test the significance of individual coefficients in models we employ wald test the waldtest is given by equation 6 the statistics under wald test follow normal distribution with a null hypothesis that the individual coefficient is equal to zero 𝑊 𝑗 𝛽 ̂𝑗 𝑆𝐸 ̂ ⁄ however it is also accepted fact that in practice model choice mainly depends on subject matter information and purpose of the analysis model selection solely based on statistical rules is rare therefore we will be combining the model selection criteria of bic with our domain knowledge and prior literature furthermore the model selection will be based on pseudo rsquare hemmert schons wieseke and schimmelpfennig has proposed to evaluate the models in categorical dependent variable regression by comparing their pseudo rsquares we will also base our model selection on pseudo rsquare summary statistics this study intends to analyze the effect of socioeconomic variables on the demand for secondary education before proceeding towards the results it is better to explore the variables in order to have a better understanding of preliminary behavior of the variables some schooling with an average of 87 years the distance from secondary school for 27120 households averaged in the range of 12 kilometers out of the sample 6850 households had a female head the age of the head averaged 4741 years for 76589 households whereas there were 61109 households with a head having age of above 40 years on average there were 1724 males in the target age group in a household households in higher incomegroup usually have more tendency to educate their children this is clear from table 5 as the proportion of households having demand for secondary schooling is increasing with income level on the other hand the proportion of households not demanding secondary education is decreasing for successive income group results and discussions this section presents the results of estimations based on the methodology defined in section 3 we have presented the marginal effects of the logit estimates for ease of interpretation for model building study uses purposeful selection of variables as proposed by bursac gauss williams and hosmer instead of step wise deterministic method of model building as the deterministic method of model selection is useful in cases where outcomes being studied are relatively new and important covariates are not well understood however in the case of demand for secondary schooling there are multiple studies that have outlined important covariates involved at household level a total of five models were estimated to analyze the demand for secondary education we employed lr test and wald test for selection of final model model selection and analysis the first model contained income group urban region household size male proportion of target age group members heads education mothers education distance from school female head and age of head the probability value for the lr test is given by prob chi2 in table 8 the lr test reveals that the null hypothesis of all coefficients being equal to zero has been rejected as the prob chi2 is less than our significance level of 005 therefore we reject the null hypothesis and conclude that at least one variable has a nonzero coefficient in order to identify insignificant variables we employ the wald test on each coefficient the variables that have insignificant coefficients will be dropped to avoid overfitting in our model the probability value for the wald test is provided in parenthesis for each coefficient in table 8 it may be noted that the coefficients of income groups 4 5 and 6 are insignificant however this is our main variable and we dont drop it from our models among other variables urban region distance from school and female head are insignificant as their pvalue for the wald test is greater than our significance level of 005 therefore we fail to reject our null hypothesis of the coefficient of these variables being equal to zero the pseudo rsquare represented by pseudo r2 in table 8 has a value of 0087 in model 1 in model 2 we drop household size as it has a negligible coefficient value and retaining it may result in overfitting the model additionally ravallion and wodon have also shown the insignificant impact of household size on demand for education furthermore household heads education has a very small coefficient therefore we drop it from our model but retain mothers education the lr test revealed that the model is significant at a significance level of 005 as the value of prob chi2 is less than the significance level of 005 therefore we conclude that at least one variable in model 2 is significantly different from zero individual coefficients have been tested by applying the wald test it may be noted that income categories higher than lower middle income are insignificant similarly urban region and distance from school are also insignificant the value of pseudo rsquare has declined to 0077 showing a lesser fitness of the model with the data in model 3 the study introduces additional variables average education of elders and heads education and drops female head the variable of heads age has been replaced with age of head 40 plus the overall model is significant at a significance level of 005 however heads education has become insignificant the variable of heads age 40 plus is significant the pseudo rsquare has shown improvement and reached 0087 model 4 drops the heads education which was insignificant in the earlier model it includes the variable of female head dropped earlier the results show that the overall model is significant and all the variables except income group of upper income are significant however the goodness of fit has declined from 0087 to 008 therefore we try another model to see if it reduces the overfit of model 4 model 5 eliminates the variable distance from school as the correlation of this variable with five out of 11 variables in the correlation matrix is insignificant the result shows that the overall model is significant the coefficients of all variables except the income group of upper income are significant furthermore the goodness of © 2024 aess publications all rights reserved fit represented by pseudo rsquare has also improved from 008 to 013 this shows that this model is a better fit for our data as compared to earlier models therefore we will use this model for interpretation table 8 presents the marginal effects of independent variables on households demand for secondary education the results show that higher income levels significantly increase the demand for secondary schooling which shows that secondary schooling is considered a normal commodity among households in pakistan the coefficient of income elasticity increases for successive income groups this result validates our first research question about the normality of secondary schooling on average households from lower income group are 38 percent more likely to demand secondary schooling as compared to lower lower income group the magnitude of the coefficient increases for successive income groups with upper middle income households being 12 percent more likely to demand secondary schooling as compared to lower lower income group households households from lowerincome groups have a higher opportunity cost of educating a child in a country like pakistan where child labor is a common phenomenon poor families put their children to work at an early age if poor families choose to educate a child they have to forgo the income earned by that child on the other hand rich families have lower opportunity cost for educating a child therefore they tend to have higher demand as compared to poor families these results are consistent with hamid where she has shown poverty to be a detriment to school attainment our second research question relates to the headship of female and its impact on the decision to demand secondary schooling literature has shown that households headed by females place more emphasize on the education of children as compared to households headed by males chudgar found that households headed by females tend to focus more on the education of children as compared to their counterparts our results also show that the likelihood of demand for secondary schooling is higher by 97 percent for households headed by females as compared to their counterparts this may be the result of the nonbias behavior of female heads towards the education of female children similarly young females may also have better bargaining power in households headed by females which may increase the chances of demand for secondary education it can be observed that urban region has a significant positive effect on demand for secondary education the results show that a household in an urban region is 77 percent more likely to demand secondary education as compared to a household in rural region this may be the result of access to secondary schools in urban areas usually there are more educational institutes in urban areas as compared to rural areas therefore people in urban areas find it easier to enroll their children in school our result is in line with the expected outcome of a positive association between urban region and demand for secondary schooling this result is also in line with qureshi where they have shown a positive impact of urban region on demand for schooling in pakistan where male children are preferred due to their contribution to the household economy it is expected that an increase in the male proportion of the target age group will lead to an increase in demand for secondary schooling atif et al the results show that it has a strong positive and significant effect on households demand for secondary education the demand for secondary schooling increases by 63 percent with an increase of 100 percent in the male proportion of target age group members this indicates that people place more weight on the education of male members as compared to female members these findings are also supported by qureshi who showed that being female decreases the likelihood of being enrolled at school educated families tend to give higher weight to the education of their children our results show that the average education of elders increases the likelihood of demand for secondary schooling with an average increase in one year of schooling for elders the chances of demand for secondary school increase by 4 percent this low impact may be due to the lower schooling years of elders as indicated in the summary statistics the average years spent in school by elders stood at 87 however if they have obtained higher schooling they might have motivated younger household members to enroll in school a household heads age also significantly affects the demand for secondary education a household with a head of 40 years plus is 18 percent more likely to demand secondary schooling as compared to a household with a head below 40 years of age with a higher age it is possible that a head may be earning more therefore they choose to educate their children similarly higher age is also an indication of more experience in life these results are also in line with ullah and hussain who have shown that age of household head has a positive relationship with demand for education income group specific analysis in order to answer our third question we further dive into analyzing the effect of household characteristics on demand for secondary here we have divided our sample into six groups according to the income groups defined earlier we have employed model 5 on these income groups as it avoids overfit to the data table 9 presents the results of logit estimations for each group the lr test reveals that the models of all groups are significant at 005 level of significance furthermore the wald test also shows that majority of coefficients are significantly different from zero finally the pseudo rsquare indicated by pseudo r2 also has value greater than 01 which indicates that the models are good fit to the data it can be observed that urban region has significant effect on the decision of households belonging to all income groups except income group 6 the coefficient of urban region is having highest value for upper middleincome group these results are supported by qureshi where they have shown a positive impact of urban region on demand for schooling male proportion of target age group in a household also has significant effect on the decision of households it may be noted that income group 1 and 6 have the highest magnitude of coefficient with an increase of 100 percent in male proportion of target age members the households of income group 1 and 6 become 76 and 80 more likely respectively to demand for secondary schooling on the other hand the magnitude declines for income groups 234 and 5 this may be the result of high priority given to the education of boys as compare to education of girls the lowest income group may choose to prefer education of boys over education of girls due to formers contribution in household income even after getting married whereas females leave the house of parents after marriage and dont contribute in the income of family therefore while making choice between educating a boy or a girl parents prefer boys however the reason of preference for education of boys among high income families may need to be explored these results are also supported by qureshi average education of elders has a unique characteristic it has significant positive effect in determining the decision of households from all income groups however the magnitude of coefficient is strong for first three income groups this shows that having educated elders is more effective in increasing the likelihood to demand secondary schooling among households of income groups 12 and 3 having a female head also increases the likelihood of households demand for secondary education however its effect on decision of households from income groups 5 is insignificant as indicated in table 6 majority of households have males as their head female heads are very rare and are found mostly among households of lower income group this may indicate that females dont become head of household by choice they may become head if there is no male member in the household this situation may be a representative of tough time for that household therefore females from lower income groups choose to educate their children so that their miseries and hardships may end after getting education age of head above forty years has strong positive effect on the decision of households from all income groups except income group 6 this may show that heads who are over forty years of age are more cognizant of importance of secondary education this result is also supported by our earlier estimates and with ullah and hussain © 2024 aess publications all rights reserved conclusion all united nations member states adopted the sustainable development goals in 2015 target 41 of the sdgs aims to provide free equitable and quality primary and secondary education for all boys and girls however pakistan is lagging far behind in ensuring the completion of secondary education for its population this study attempted to explore the role of different socioeconomic variables in determining a households decision to enroll its members in secondary school the results show that the urban region education level of elders in household having a female head having a mature head distance from secondary school and male proportion of the target age group increase the likelihood of having demand for secondary education in a household furthermore the results also reveal that secondary education is considered a normal commodity among pakistani households as its demand increases with a rise in household income in light of these results it is recommended that policies targeting lower incomegroups may be introduced to increase the enrollment at the secondary education level in this regard the policy of midday meal adopted in india may also be adopted in pakistan the adoption of such a policy will not only increase enrollment but it will also mitigate classroom hunger similarly policies may be introduced to increase the education profile of females which will also increase secondary enrolment mature heads tend to have demand for secondary education however there is a need to introduce policies which may increase awareness of secondary education among heads of below 40 years of age competing interests the author declares that there are no conflicts of interests regarding the publication of this paper

secondary education for all is one of the uns attainable goals many countries including pakistan are struggling to achieve this target earlier research has attempted to analyze the determinants of secondary schooling by taking the total income of households however households of different income groups respond differently to varying socioeconomic factors this study attempts to identify the householdlevel socioeconomic determinants of secondary schooling across different income groups in pakistan it utilizes national survey data from the pakistan social and living standards measurement pslm survey 201920 we selected households from the dataset that had at least one member of secondary school age 13 20 years households that enrolled a secondary schoolage member in school or whose member achieved secondary schooling were categorized as having demand for secondary schooling furthermore instead of taking the total income of households study takes six categories of income the results of logit estimation show that demand for secondary schooling increases across successive income groups indicating secondary schooling is a normal commodity the proportion of male schoolgoing age members and having a female head increase the likelihood of demand for secondary schooling the study recommends that policies to increase enrollment at the secondary level may focus more on lowerincome groups and on the education of females contribution originality this study takes six income categories of households and analyzes the effect of these categories on the demand for secondary schooling furthermore it divides households into six categories and analyzes the impact of socioeconomic factors on the decision to demand for secondary schooling separately

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background there are substantial inequalities in morbidity and premature mortality between individuals with mental health problems and those without and much of this inequality is due to smoking 1 2 3 tobacco control strategies have led to an overall decline in smoking prevalence in countries such as the uk and us however there remains a large gap in smoking prevalence between people with and without mental health problems among those with a common mental health disorder in england smoking prevalence remains around 50 higher 4 and this increases further for more severe mental disorders 5 figures for the us similarly show an increased burden of smoking among those with mental health problems 67 the relationship is complex but appears to be bidirectional 8 9 10 previous research has consistently shown that smokers with mental health problems on average smoke more heavily 457 and extract more nicotine from each cigarette than those without mental health problems 5 people with schizophrenia bipolar disorder depression and anxiety who smoke experience more severe symptoms and require higher doses of some psychotropic medicines than nonsmokers 5 smoking is also associated with poorer treatment outcomes compared with nonsmokers with mental health problems smokers with mental health problems spend longer time in hospital and less time out of hospital 11 there is some evidence mainly from the us that smokers with mental health problems are as likely to make a quit attempt as other smokers 12 but cessation rates are lower successful quitting is associated with improved mental health specifically reduced anxiety depression and stress and increased psychological quality of life and positive affect 13 additionally for specific medications for severe mental illness quitting may reduce the required dosage 5 and thus associated side effects preventing the uptake of smoking prompting more quit attempts and improving access to smoking cessation or harm reduction interventions are needed to reduce the excess burden of disease and premature mortality associated with smoking among people with mental health problems research about the effectiveness of smoking cessation interventions among smokers with severe mental health problems is promising 1415 however advancement of smoking cessation for smokers with mental health problems is limited particularly in england and the rest of the uk by a lack of population level studies about smoking prevalence motivation to quit attempts to quit and harm reduction behaviours which are needed to quantify the need and identify barriers and opportunities for interventions this study aimed to answer the following questions 1 what is the mental health status of current cigarette smokers and recent exsmokers in england 2 what are the characteristics of smoking behaviour among pastyear smokers with and without mental health problems 3 what are the characteristics of harm reduction behaviour among current cigarette smokers with and without mental health problems 4 what is the frequency of quit attempts in pastyear smokers with and without mental health problems methods procedure the present study uses selfreported data from monthly crosssectional household surveys of representative samples of the population of adults in england collected as part of the ongoing smoking and alcohol toolkit study the methodology for the toolkit study has been described in detail by fidler et al 16 and to date it has been used as the basis for approximately 85 peerreviewed publications briefly each month a new sample of approximately 1700 adults aged 16 years or older in england completes a facetoface computerassisted survey after stratification by geodemographic classification of population small geographical areas containing approximately 300 households are allocated randomly to interviewers who visit households within the locality and conduct computerassisted facetoface interviews with one member of a household in those areas until a prespecified quota tailored to the area is fulfilled this form of sampling has benefits over conventional quota sampling because the allocation of small areas to interviewers reduces the impact of selection bias resulting from the selection of properties 17 response rates cannot be calculated because of the lack of a definitive gross sample all units fulfilling the criteria of a given quota are interchangeable within the areas for the present study measures of mental health were added to the survey for 24 monthly waves from january 2016 to december 2017 measures all measures were selfreported generally questions were completed in an interview with the interviewer recording the responses the mental health questions were selfcompleted by the interviewee on a laptop following familiarisation using similar example questions sociodemographic measures included age gender and occupational grade smokingrelated measures included smoking status assessed using which of the following best applies to you please note we are referring to cigarettes and other kinds of tobacco that you set light to and not electronic or heatnotburn cigarettes a i smoke cigarettes every day b i smoke cigarettes but not every day c i do not smoke cigarettes at all but i do smoke tobacco of some kind d i have stopped smoking completely in the last year e i stopped smoking completely more than a year ago f i have never been a smoker those who had stopped smoking more than a year ago or had never been smokers were excluded as were the 186 smokers who reported currently smoking other tobacco products those selecting responses a or b were categorised as current smokers current smokers and those who had stopped in the last year were categorised as pastyear smokers those who had stopped smoking may have included a small number of respondents who had smoked products other than cigarettes pastyear cigarette smokers reported type of cigarette smoked strengths of urges to smoke 19 and heaviness of smoking index current cigarette smokers also reported motivation to stop smoking 21 and average spend on tobacco per week harm reduction measures for all pastyear smokers included number of attempts to quit smoking in the past year and whether abstinence from smoking of one month or longer was achieved during the past year which was derived from questions about how long each of up to three quit attempts undertaken in the last year lasted before going back to smoking current smokers were additionally asked whether they were currently attempting to cut down on the number of cigarettes and whether they were currently using nicotine replacement therapy or ecigarettesvaping products for cutting down temporary abstinence or other reasons mental health measures included three indicators of mental health problems 2223 the list of diagnoses based on a report on adult psychiatric morbidity in england 24 response options excluding the final three were presented in a randomised order individual diagnoses were dummycoded for analysis a composite measure of any diagnosis was derived 2 pastmonth distress measured using the k6 screener for mental distress in the past 30 days 2526 during the past 30 days about how often if at all did you feel … nervous hopeless restless or fidgety so depressed that nothing could cheer you up that everything was an effort worthless the options were presented in a randomised order and for each the respondent indicated one of the following all of the time most of the time 3 some of the time 2 a little of the time 1 none of the time these options were presented in this or the reverse order for the entire k6 additional response options dont know prefer not to say were provided the k6 has been validated and used in a number of population surveys 25 26 27 28 29 30 31 32 33 34 35 a sum score with a possible range from 0 to 24 was calculated and following common practice scores of 13 and higher categorised as serious distress 2529 some publications have additionally used a category of moderate distress 31 which was also used 3 pastyear treatment respondents who selected any of the responses for ever diagnosis were asked for those they selected in the last 12 months which of the following conditions if any have you had any treatment or taken any prescribed medication for sample selection in 2016 and 2017 40831 adults were surveyed of whom 7651 were pastyear smokers who were asked the mental health questions smokers who exclusively smoked tobacco products other than cigarettes were excluded those who did not complete the mental health questions or selected dont know or prefer not to say in response to any of them were also excluded leaving 6280 pastyear smokers with information on mental health finally those with missing data on any of the other variables included in the present analysis were excluded leaving 6071 pastyear smokers for the main analyses of whom 5637 were current cigarette smokers and 434 recent exsmokers type of cigarette smoked was missing for 164 reducing the sample to 5907 pastyear smokers and 5506 current cigarette smokers if type of cigarette was included in analysis analysis pastyear smokers who completed the mental health information were compared with those who did not complete the mental health information or responded dont know or prefer not to say to address research question 1 weighted proportions were used to describe the prevalence of ever having had any mental health diagnosis since the age of 16 the prevalence of moderate and serious distress in the past month and the prevalence of treatment for mental health problems in the past year overall and by diagnosis to address research question 2 weighted proportions were calculated and chisquare statistics were used to compare smoking status type of cigarette smoked dependence of pastyear cigarette smokers with and without any diagnosis with minimal moderate and serious pastmonth distress and with and without pastyear treatment for chisquare tests cramers v was used as effect size cramers v can range from 0 to 1 additionally for current cigarette smokers spend on tobacco was compared using analyses of variance and independent samples median tests to address research question 3 weighted proportions for cutting down using ecigarettes using nrt using either ecigarettes or nrt motivation to stop smoking and having achieved at least one month of abstinence in the past year were calculated for current cigarette smokers and compared using chisquare statistics with cramers v as effect size to address research question 4 the mean number of quit attempts made in the past year was compared among pastyear smokers with and without mental health problems a dichotomised version of this measure was used to calculate prevalence and 95 confidence intervals of having made at least one quit attempt and as outcome in logistic regressions assessing its association with ever diagnosis pastmonth levels of distress and pastyear treatment among pastyear smokers unadjusted models were followed by models adjusting for sociodemographics additional models adjusted for motivation to stop smoking and type of cigarette as this information can only be collected from current cigarette smokers any quit attempt had been unsuccessful the analyses plan was preregistered on the open science framework the following changes were made from the registration research question 1 was added to provide a fuller description of the population the present research questions 2 and 3 were initially presented as a single research question to increase consistency smokers of other tobacco products such as pipes or cigars were excluded from all analysis results noncompletion of mental health information became slightly more likely with increasing age and was more likely for nondaily cigarette smokers and current nrt users but differences were small mental health overall 359 of pastyear smokers reported ever having been diagnosed with at least one mental health problem since the age of 16 340 reported having experienced moderate or serious distress in the past month and 219 of the sample had received treatment for a mental health in the past year among those who had ever been diagnosed with a mental health problem the most common diagnosis was depression followed by anxiety in the past year 610 of those with a diagnosis had received treatment for this diagnosis however this ranged from 79 for problem gambling to 641 for psychosis in general indicators of mental health problems were more common among younger age groups women and lower socioeconomic groups smoking about 7 of the sample reported having stopped smoking completely in the past year most participants were daily cigarette smokers and there was little difference between those with and without mental health problems overall about half smoked rollyour own exclusively or alongside manufactured cigarettes and this was more common among cigarette smokers with mental health problems the vast majority of pastyear smokers experienced at least some urges to smoke although few had high heaviness of smoking ratings stronger urges and heavier smoking were more common among those with mental health problems current cigarette smokers with data on spend available on average spent £2261 per week on tobacco or cigarettes this was lower among those with any diagnosis or distress but not by treatment likely in part due to higher rates smoking rollyour own harm reduction overall 461 of smokers were cutting down 194 were using ecigarettes and 85 nicotine replacement therapy all three harm reduction behaviours were more common among smokers with a mental health problem albeit all with cramers v ≤ 01 about one in seven reported motivation to stop smoking within the next three months this was slightly more common among those with any indicator of mental health problems with cramers v below 01 in the last year 129 had achieved at least one month of abstinence this did not differ by ever diagnosis or pastyear treatment but by level of distress those with minimal distress were least likely and those with moderate distress most likely to have achieved a month of abstinence again with cramers v below 01 quit attempts just under a third of those who smoked in the past year had made at least one quit attempt in that the strength of these associations remained very similar in adjusted analysis when including only current smokers smokers with any diagnosis pastmonth distress or pastyear treatment were also more likely to have made a quit attempt than smokers without these indicators of a mental health problem discussion different indicators of mental health problems showed that substantial proportions of pastyear smokers in england have mental health problems just over a third reported ever having had a diagnosis of a mental health the median number of quit attempts was 0 for all groups the mean number of quit attempts overall was 059 this was similar for those with and without diagnosis 213 p 014 with and without pastyear treatment m 056 sd 317 problem and around 60 of them had received treatment in the last year suggesting an ongoing issue which was also indicated by just over a third experiencing moderate or serious mental distress in the past month those with an indication of a mental health problem were more highly dependent and more likely to smoke rollyourown cigarettes cigarette smokers with a mental health problem were however more likely to be motivated to stop smoking and to engage in harm reduction behaviours such as use of ecigarettes or nrt pastyear smokers with mental health problems were more likely to have made at least one quit attempt in the past year and this remained true when including only current smokers yet there was little difference by mental health in having achieved at least shortterm abstinence among all pastyear smokers suggesting that quit attempts may be less successful in those with mental health problems the prevalence of mental health problems found in this population survey is in line with previous estimates that 30 of smokers in the uk have evidence of mental disorder 5 and an estimate that 274 of adults in england have ever been diagnosed with a common mental health problem the level of moderate and severe distress found in pastyear smokers in england is similar to those from a household survey in the us which found that in 2015 258 of current cigarette smokers had moderate and 94 serious distress in the past month 12 both a us survey 1230 and the present survey found that those with psychological distress were more likely to have made at least one quit attempt in the past year the present finding that those with a mental health problem are at least as likely to be motivated to stop smoking is in line with earlier findings which used different measures to measure related constructs 43037 previous research from the us found that current cigarette smokers with mental health problems were not statistically more likely to be using electronic cigarettes this is in contrast to the present findings 3839 the present study had several limitations timing or causality of events cannot be established it could for example be argued that an unsuccessful quit attempt in the pastyear could have increased distress and even increased the need for treatment for a mental health problem however associations were very similar for the different indicators of mental health problems making this direction of causality appear less likely all measures were selfreported more comprehensive instruments may have differed in their detection of mental health problems because the survey is a household survey it excludes people who are too unwell to take part or in healthcare institutions thereby excluding those with the most severe mental health problem because respondents were asked to select the single option that best describes their smoking use of other tobacco products such as pipes cigars or shisha remained unreported among cigarette smokers however a strength is that data came from a longstanding established population survey and a sample representative of the adult population in england the present study is the first to provide detailed populationlevel evidence on motivation to quit smoking attempts to do so and harm reduction behaviours of smokers in england by mental health status it is also the first to report that smokers with a mental health problem are more likely to engage in harm reduction behaviours compared to those without some implications for policy and clinical practice can be drawn from the findings the relatively higher levels of motivation attempts to stop smoking and harm reduction behaviours such as ecigarette use among smokers with mental health problems compared to those without should be capitalised on by clinicians to reduce the burden from smoking specific challenges such as higher dependence on tobacco need to be addressed by making effective support available a combination of behavioural support and medication is most effective in the wider population of smokers and has been shown to be effective for smokers with severe mental illness 1415 and for smokers with and without mental health problems making quit attempts 40 in quit attempts and accompanied by behavioural support ecigarettes have been shown to be more effective than nrt 41 in the smoking toolkit study they were also associated with increased success rates for smokers with and without mental health problems 40 additionally smaller studies in smokers with severe mental illness who were not interested in quitting found that substantial proportions reduced their smoking by at least 50 when supplied with ecigarettes 4243 clinicians should ensure that patients have their smoking status identified and recorded in health care records all smokers irrespective of their mental health status should be advised about the most effective way to quit and either provided with treatment or referred for specialist stop smoking support 44 ensuring harm reduction strategies are accessible should also be considered recently in england the national health service has committed to funding tobacco treatment services for all smokers admitted to hospital including the option to switch to ecigarettes for mental health patients 45 future research needs to assess associations for specific mental health problems or groups of problems should also be assessed in addition to a catchall category of any diagnosis conclusions about a third of smokers in england have mental health problems this population is more likely to be young female and from lower socioeconomic groups they are more dependent on tobacco smoking but also more likely to engage in harm reduction behaviours more motivated and more likely to attempt to stop smoking interventions should address their increased dependence but also leverage the higher prevalence of harm reduction behaviours motivation to stop smoking and attempts to stop smoking in this population supplementary information supplementary information accompanies this paper at 1186s1288902009308x additional file 1 supplementary file 1 table s1 comparison of pastyear smokers who completed the mental health information and those who terminated the survey prior to the section or responded dont know or prefer not to say additional file 2 supplementary file 2 table s2 weighted prevalence of individual diagnosis and pastyear treatment for each diagnosis competing interests the authors declare no competing interests

background tobacco control strategies have engendered overall declines in smoking however a large gap remains between people with and without mental health problems causing substantial health inequalities populationlevel information on barriers and opportunities for improvements is scarce we aimed to assess mental health status of cigarette smokers and recent exsmokers pastyear smokers in england and smoking and harm reduction behaviour and quit attempts by mental health status methods data were collected from 5637 current and 434 recent exsmokers in 201617 in household surveys of representative samples of adults we calculated weighted prevalence of different indicators of mental health problem a ever diagnosis b none moderate serious pastmonth distress c pastyear treatment we compared weighted smoking status cigarette type dependence motivation to stop smoking cutting down use of nicotine replacement therapy or ecigarettes shortterm abstinence and quit attempts according to mental health status results among pastyear smokers 359 ever had a diagnosis 243 had experienced moderate an additional 97 serious pastmonth distress 219 had had pastyear treatment those with an indication of a mental health problem were more highly dependent and more likely to smoke rollyourown cigarettes but also more likely to be motivated to stop smoking to cut down use nicotine replacement therapy or ecigarettes and to have attempted to quit in the past year conclusions about a third of cigarette smokers in england have mental health problems interventions should address their increased dependence and leverage higher prevalence of harm reduction behaviours motivation to stop and attempts to stop smoking

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background in the netherlands as in many other european countries inequalities in health exist between those of high and those of low socioeconomic status 1 life expectancy between the lowest and highest educated groups differs by 73 years for men and 64 years for women differences in healthy life expectancy are even larger namely 192 years for men and 206 years for women 2 differences in life expectancy between the lowest and highest income quintiles show the same pattern 3 moreover a lower ses is associated with a higher prevalence of most chronic diseases including mental disorders selfassessed poor health and lifestylerelated risk factors such as current tobacco smoking and obesity 145 despite many efforts to reduce socioeconomic health inequalities in the netherlands most inequalities in health and lifestyle between educational levels remained unchanged 4 5 6 besides artefacts such as measurement error two major explanations for socioeconomic health inequalities have been proposed causation and selection causation relates to causal mechanisms through which ses and social relationships potentially affect health status and the risk of dying selection or reverse causation refers to a set of pathways where unhealthy individuals may reduce their social position or become socially more isolated as a consequence of their inferior health status 7 for selection a distinction is made between direct selection where a persons health status affects their social status and indirect selection meaning that some personal attributes such as cognitive ability coping styles personality and fitness influence both the ses and the health of a person 7 8 9 10 several studies have shown that various personality traits partly explain the social gradients in mortality health behaviour andor depression symptoms 11 12 13 14 15 none of these studies however studied the role of the distressed or type d personality in recent years type d personality was introduced in the cardiovascular literature as a valid and clinically relevant construct that has been associated with a threefold increased risk of poor prognosis and morbidity in cardiac patients 16 type d personality refers to a general propensity to psychological distress that is defined by the combination of negative affectivity and social inhibition 17 people who score high on negative affectivity have the tendency to experience negative emotions while people who score high on social inhibition have the tendency to inhibit selfexpression because of fear of disapproval by others persons with high levels on both personality traits are classified as having a type d personality 17 given the clinical relevance of type d personality in cardiovascular populations it might also be of interest to assess the relevance of type d personality for health risks and outcomes in the general population 18 following the indirect selection hypothesis it was hypothesized that type d personality would lead to both a lower ses and poorer health thereby explaining the relationship between a lower ses and poorer health this hypothesis was partly supported in a recent review of type d studies in the general population concluding that type d personality is a vulnerability factor that may affect not only people with medical conditions but also the health status of individuals from the general population 19 however the authors did not take ses into consideration type d personalities may deal with stress in a less adaptive way 20 type d personality is associated with major stressors such as traumatic events and social isolation and with clinically significant burnout depression and panic disorder 2021 these difficulties in dealing with stress might affect the upward social mobility or even increase the downward social mobility of type d personalities moreover the indirect selection mechanism might be explained by genetic factors that predispose for a type d personality as well as for a low ses for example through intelligence 9 therefore the present study was designed to expand our understanding of the role of type d personality as an explanation of health inequalities with the aim of quantifying the contribution of type d personality to the association between ses and different lifestylerelated risk factors and health methods study design this study used crosssectional data from two surveys among the general population collected by two regional health services in the netherlands to support local public health policy one survey in the region westbrabant and one survey in the municipality shertogenbosch the capital city of the province noordbrabant rhss in the netherlands are authorised to sample the municipal basic administrations for health surveys for these two surveys inhabitants aged between 19 and 64 years were randomly sampled from the mba stratified by municipality the surveys were approved by the board of directors of the rhss involved according to the dutch medical research involving human subjects act these surveys were exempted from ethics approval because they did not meet the criterion that people are subjected to procedures or are required to follow rules of behaviour participants received a postal invitation to consent to participation by filling out an enclosed questionnaire either on paper or with a personal logon code through the internet the invitation also declared that the questionnaires would be processed anonymously data collection took place between october and december 2005 the initial sample for these two surveys consisted of 15025 subjects of whom 560 participated after a maximum of two reminders in addition 7470 inhabitants were sampled nonrepresentatively for example in some deprived neighbourhoods or in some municipalities with a response of 492 main variables socioeconomic status the dataset contained two indicators for ses education and income we defined low education as the case where the highest completed education is none or primary school and low income as a net monthly household income below the dutch standard type d personality the dataset contained the type d scale14 a short easytouse and valid construct consisting of 14 questions about personality with a 5point likert response scale ranging from 0 to 4 the ds14 comprises two subscales the negative affectivity subscale and the social inhibition subscale a predetermined cutoff of ≥ 10 on both subscales was used to classify participants as type d personality 17 in the current dataset the ds14 showed excellent internal consistency with cronbachs α 087 for both subscales lifestylerelated risk factors and health status the dataset contained several variables as determinants of health and health status the choice of the indicators used in this study was mainly based on the burden of disease in the dutch population leading to increased attention in dutch health policy for lifestylerelated risk factors three indicators were used current tobacco smoking unsafe alcohol use defined as the consumption of more than 21 glasses of alcoholic beverages weekly for men and more than 14 glasses weekly for women and obesity defined as a body mass index of 30 or more 22 for adverse health outcomes five indicators were used selfassessed poor health defined as fair or poor health based on the first question of the sf36 diagnosed by a physician as having one or more chronic illnesses on a list of eighteen diagnosed by a physician as having diabetes mellitus diagnosed by a physician as having cardiovascular disease and high psychological distress 2324 the k10 and its dutch translated version have a good discrimination ability with respect to anxiety or depression disorders in the general population 232526 in our dataset the k10 was available only for the municipality of shertogenbosch analysis figure 1 presents our model of indirect selection in a very simplified schematic way for it ignores the bidirectional pathway between low ses and health under the indirect selection hypothesis type d personality would be related to low ses as well as to health moreover under that hypothesis an association between low ses and health would be explained by type d personality yet it should be noted that because of the crosssectional nature of our data the mechanisms of indirect selection and causation cannot be distinguished the abovementioned associations could also occur in the case of causation when a lower ses would be associated with both a type d personality and poorer health while at the same time type d personality would be related to poorer health the following associations were assessed and quantified from the perspective of indirect selection all adjusted for age sex and municipality 1 the association between type d personality and a low ses 2 the association between type d personality and health 3 the association between low ses and health 4 the association between low ses and health conditional on type d personality and 5 modification of the effect of low ses on health by type d personality for the first analysis we computed the odds ratios with 95 confidence intervals for low ses as a function of type d personality using logistic regression analysis for the second third and fourth analyses we computed relative risks with 95 confidence intervals for type d personality and low ses as risk factors for of health using multivariate generalized linear models in addition this relative risk for low ses was adjusted for type d personality in the fourth analysis in all these analyses each reference category contained all persons without the studied characteristic for the fifth analysis a new variable was constructed for all four possible response combinations of type d personality and low ses using as the reference category the category where both type d personality and low ses were absent we computed relative risks with 95 confidence intervals for the other three combinations of type d personality and low ses as risk factors for of health using multivariate generalized linear models we computed the relative excess risk due to interaction in order to assess and quantify interaction on an additive scale as suggested by rothman 27 the 95 confidence intervals for the reris were computed with a bootstrapping procedure with a sample size of 10000 using knols bootstrapping script adjusted for rplus 28 the covariates sex age and municipality were taken into consideration for all associations examination of the occurrence of type d personality over the categories of ses and health showed that the prevalence of type d personality increased with decreasing education and income with regard to lifestylerelated risk factors the most striking finding was the highest prevalence of type d personality in the alcohol abstainers as to health there seemed to be a doseresponse relationship between on the one hand selfassessed health and psychological distress and on the other hand the prevalence of type d personality the poorer the selfassessed health or the higher the psychological distress the higher the prevalence of type d personality using the total dataset adjusted for sex age and municipality type d personality was significantly associated with both indicators of a low ses low education and low income persons with a type d personality had a small but significantly higher risk of current tobacco smoking but not of unsafe alcohol use and obesity furthermore type d personalities were at a higher risk of selfassessed poor health chronic disease cardiovascular disease and high psychological distress type d personalities did not have an elevated risk of diabetes the associations all remained statistically significant when they were analyzed conditionally on low education or on low income though some relative risks moved slightly towards the null value persons with low education as well as those with a low income had significantly higher relative risks for all studied indicators for health except for unsafe alcohol use the risk of unsafe alcohol use was significantly lower for persons with a low education all associations remained statistically significant when they were analyzed conditionally on type d personality though some relative risks moved slightly towards the null value interaction between type d personality and low ses on an additive scale was significant for the effect of low education on high psychological distress and for the effect of a low income on selfassessed poor health and on high psychological distress this means for example that the relative risk for selfassessed poor health is 14 higher in type d personalities with a low income than if there were no interaction between type d personality and low income because the absolute background risk was 58 this means that the absolute excess risk due to interaction is 81 accordingly the excess risk due to interaction for high psychological distress is 271 for the interaction between type d personality and low education and 80 for the interaction between type d personality and low income based on the background prevalence in the region shertogenbosch discussion some methodological limitations should be considered when interpreting the results of our study first due to the crosssectional nature of the datasets it is not possible to make any definite inference on causality however we assumed that both type d personality and a low ses precede the outcomes for health second the response of type d personalities persons with a lower ses and those with poor health could be lower than that of others selective nonresponse of these persons would lead to underestimation of their prevalence and would lead to underestimation of the real risk ratios only when type d personalities andor persons with a lower ses did not respond in the presence of poor health third type d personalities might respond differently to particular questions for example type d personalities are inclined to perceive poor health more often than non type d personalities 29 socioeconomic differences in life expectancy in good health might partly be explained by this inclination because this outcome is based on selfassessed health combined with mortality moreover in the presence of health complaints type d personalities are less likely to consult a physician as compared to non type d personalities for physical or a 21 glasses alcoholic beverages weekly for men 14 glasses alcoholic beverages weekly for women b during the last 12 months from among the following 18 chronic diseases 1 diabetes 2 stroke cerebrovascular accident or transient ischemic attack 3 myocardial infarction 4 other severe heart disorder such as heart failure or angina pectoris 5 cancer 6 migraine or regular severe headaches 7 high blood pressure 8 constriction of the blood vessels in stomach or legs 9 asthma chronic bronchitis pulmonary emphysema or copd 10 severe or persistent intestinal disorders for than 3 months 11 psoriasis 12 chronic eczema 13 incontinence 14 severe or persistent back disorders 15 articular degeneration of hips or knees 16 chronic arthritis 17 other severe or persistent disorder of neck or shoulder 18 other severe or persistent disorder of elbow wrist or hand c based on three questions stroke cerebrovascular accident or transient ischemic attack myocardial infarction other severe heart disorder such as heart failure of angina pectoris table 3 results for the conditional associations a of type d personality and low ses conditional on low education 11 09 11 26 12 09 15 79 mental health problems 30 31 32 this could result in under diagnosis and consequently underestimation of real risk ratios of chronic diseases fourth for the reason of comprehensiveness weve chosen to dichotomize the measures of ses which could have been used as ordinal variables in the analysis therefore due to measurement imprecision and loss of data our associations were measured more conservatively than by using ordinal variables possibly leading to underestimation of the association and interaction measures fifth we did not select some covariates that might be relevant particularly ethnicity for example nonwestern respondents in the westbrabant region more often had low education and a low income than western respondents in addition among the nonwestern respondents in this region the prevalence of type d personality was much higher than among western respondents therefore we repeated our analyses on the subset of western respondents and that showed that most of the results remained essentially unchanged sixth some questions of the k10 to assess psychological distress seem to overlap three questions of the ds14 negative affectivity subscale nevertheless the k10 refers to a specific time period whereas the ds14 refers to the personality of the respondent as a stable trait or disposition in fact the prevalence of type d personality was much higher than the prevalence of high psychological distress moreover several followup studies of cardiac patients showed that type d personality predicts depression even after taking account of its baseline value 16 in addition the questions for social inhibition an essential condition for the definition of type d personality do not overlap the k10 conditional on low income 11 09 11 25 12 09 14 73 low education unconditional 14 08 17 24 12 18 142 hence assuming that type d personality and low ses merely precede most health outcomes our findings suggest that type d personality does not explain the socioeconomic health inequalities but is a risk factor for 4 11 12 20 11 16 18 22 only type d 10 09 adverse health outcomes in addition to low ses moreover for some outcomes type d personality even interacts with a low ses to show an excess risk 11 26 11 08 14 in this communitybased study type d personality was associated with an increased risk of adverse health outcomes including cardiovascular disease and poor perceived physical and mental health furthermore type d personality was related to smoking but not to obesity or diabetes type d personality could have affected health through pathways that were not assessed in this study for example others have shown that type d personality is related to lack of physical exercise 18 earlier findings in cardiac patients suggest that type d personality in itself could lead to stressrelated health problems due to elevated cortisol and proinflammatory cytokine levels and a decreased variability of heart rate 33 34 35 36 37 another interesting finding in our study was the higher prevalence of type d personality in the alcohol abstainers as compared to the prevalence among safe drinkers by comparison numerous studies have also shown that alcohol abstainers are at greater risk of adverse health outcomes than moderate drinkers 38 our results might suggest that type d personality is more related to alcohol abstinence as a risk factor for adverse health outcomes than to unsafe alcohol use however a german study found that type d personality was associated with alcohol abuse in the general population 21 obviously more research is needed to clarify the role of type d personality in the association between alcohol use and adverse health outcomes conclusions our results showed that the two essential conditions for the indirect selection hypothesis were fulfilled a positive association between type d personality and low ses as well as elevated risks of a type d personality for most of the studied health outcomes even conditional on a low ses however type d personality did not explain the higher risks of a low ses for most health as we would expect in the case of indirect selection through type d personality though some relative risks moved slightly towards the null value when analyzed conditionally on type d personality our findings might already be of importance for public health policies for example based on population attributable risks the public health impact of type d personality for cardiovascular disease is greater than that of low education though less than that of a low income prevention in low ses populations may have more effect when it takes into consideration that persons with a low ses in combination with a type d personality are at highest risk of adverse health outcomes and that type d personalities irrespective of their ses need specific approaches such as the diminishing of barriers for care demand being aware of their social fears and improving their selfmanagement acknowledging that personality is difficult to change the main issue in prevention should probably be case finding and the tailoring of prevention programmes for this specific target group for this the challenge will be how to reach identify and influence individuals with these personalities in the netherlands the general practitioner knowing his patients is perhaps the most appropriate person to play a pivotal role in such programmes author details 1 academic collaborative centre public health brabant tranzo tilburg school of social and behavioral sciences university of tilburg tilburg the netherlands 2 department of health promotion regional health service hart voor brabant shertogenbosch the netherlands 3 corpscenter of research on psychology in somatic diseases department of medical psychology and neuropsychology tilburg university tilburg the netherlands 4 department of epidemiology biostatistics and hta radboud university nijmegen medical centre nijmegen the netherlands 5 centre for prevention and health services research national institute for public health and the environment bilthoven the netherlands 6 department of local health policy regional health service westbrabant breda the netherlands 7 centre for public health status and forecasts national institute for public health and the environment bilthoven the netherlands competing interests the authors declare that they have no competing interests

background in the netherlands as in many european countries inequalities in health exist between people with a high and a low socioeconomic status ses from the perspective of the indirect selection hypothesis this study was designed to expand our understanding of the role of type d personality as an explanation of health inequalities methods data came from two crosssectional dutch surveys among the general population aged between 19 and 64 years response 537 n 12090 we analyzed the relative risks of low ses assessed using education and income and type d personality assessed using the type d scale14 ds14 for different outcomes regarding lifestylerelated risk factors and health using multivariate generalized linear models results results showed that type d personality was significantly associated with low ses or 17 for both low education and low income moreover the relative risks of type d personality and low ses were significantly elevated for most adverse health outcomes unconditionally as well as conditionallythe crosssectional design hinders the making of definite etiological inferences nevertheless our findings suggest that type d personality does not explain the socioeconomic health inequalities but is a risk factor in addition to low ses prevention of adverse health outcomes in low ses populations may have more effect when it takes into account that persons with a low ses in combination with a type d personality are at highest risk

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introduction there is no doubt in it that universities have been consistently playing leading role through scientific and technical advancements especially with respect to the cognitive and intellectual development of their communities according to buckner who investigated the impact of the role of both private and public sector higher educational institutions for over five decades on the demographic and economic factors has found an impressive improvement in higher education worldwide this progress coincided with the rapid development of information and communication technology making it imperative for the universities to leverage the modern tools and applications through integrating them in the teaching and learning environments cloud computing is currently regarded as a powerful information and communication technology application on account of its multiple advantages it has a shareable advanced computing infrastructure which can be shared among them it uses education institutions moreover cloud computing is flexible scalable and costefficient thus significantly reduce the costs related to information communication technology services it can thus help the institutions to focus on the quality of their outputs and their fulltime research and teaching cloud computing provides the students abundant scope to share teaching and learning materials references research papers and scientific articles to name but a few through the files stored on cloud storage services such as dropbox or google docs cloud computing provides a synchronization feature which enables the students who have access to the cloud to work together effectively without the need for an external storage or emails or any secondary storage for the exchange of information the sharing of videos programs photos information blogging and collaborative software etc that had been formerly unavailable or expensive is fast becoming available free nowadays anyone can now access to such sources through their own web browsers and therefore it is not surprising to find the students using such resources they make it imperative for the educational institutions to take advantage of such services effectively hussonas study at alaqsa university confirmed the effectiveness of cloud computing in teaching and learning or training and for strengthening the ecosystem to use cloud computing and scale it training was conducted via a blog based on the cloud computing capabilities a study conducted by li designed a multimedia teaching system based on cloud computing and introduced its design idea system structure and applications the teaching experiment has shown that this system has a better teaching application effect and results in the better academic performance of students in comparison to the traditional teaching methods it has also been found to improve students comprehension and has both operability and feasibility denton has reported that there are many advantages of cloud computing in the field of education such as through the use of google docs and microsoft office live which have potentiality to promote and support teaching methods based on the constructive and collaborative teaching and learning steps through the use of social constructivism theory for example using cloud computing applications and services sharing files sharing materials sharing documents and epublishing motivates the education departments across the countries to adopt such technologies as they support collaborative and interactive learning which is consistent with the current norms that suggest three key tenets of social constructivist teaching and learning environment constructive activity teacherstudent interaction and social activity a study conducted by ismail emphasized the importance of advisers in the use of cloud computing in learning her findings suggest that there are statistically significant differences in the grades of students in the instructorled groups compared to those without an instructor tashkandi aljabri recommended integrating cloud computing into saudi arabian higher education offering a special model for the understanding of the induction process in addition sabi et al proposed a model to investigate and adopt cloud computing in education in the developing countries which reinforces the importance of cloud computing in higher education likewise bhatiasevi naglis study used the data that was collected from two leading universities in thailand mahidol university international college and thammasat university concluding that university students believed that cloud computing was easy to use and had innumerable benefits the students had great confidence in its advantages and services that study also found positive attitudes among the students and an urgent desire to integrate cloud computing for usage in educational sector similarly alfifi reported a number of advantages of cloud computing which in turn motivated the stakeholders in the higher education institutions to integrate cloud computing into their operations the sample study population consisted of 106 cios in higher education institutions in the united states of america who were responsible for making decisions for both technology and business policies within their organizations this study was conducted by using a distributed questionnaire and the results identified the seven key factors moving stored data in the cloud from one provider to another service quality flexibility of traditional systems adequate safeguards to store data portability cloud liability and transparency of the servicelevel agreements the results also showed a cloudcomputing adoption by cios in higher education of more than 93 per cent the theory of social constructivism came to offer a new concept of teaching and learning as a building process inside the learner through interaction with others this theory was pioneered by the russian psychologist lev vygotsky who perceived that mental development started from the outside leading into the interior where the roots of internal processes in a person were created through interaction with others and stressed that teaching and learning was a process through which learners might learn new knowledge and make sense of it on the basis of their prior knowledge and experience the highlights of wray and lewis identifying the four important principles regarding the social constructivism theory which are as mentioned here further describes • the importance of social interaction and discussion in order to build knowledge • the learner builds new knowledge based on the previous experiences and needs help to link between the past and subsequent learning • the learner has to be active and effective in the teaching and learning process and where the meaningful context is important to learning we have to remember that what is relevant for a teacher is not necessarily equally relevant to the learner • attention to the development of higher mental skills it is important in this area to look at the relationship between the social constructivist theory and cloud computing many researchers assert that social constructivism theory applies not only to education in general but also to be applied further in elearning in particular including cloud computing the research by huang liu shed light on the role of cloud computing in the education sector that learners personal environments leave positive impact through the construction strategy of the collaborative teaching and learning steps by looking at the advantages of cloud computing services as well as looking at the principles of the social constructivism theory a clearly strong link appears between them we find that cloud computing supports the foundations of the social constructivism theory which provides the learners with good opportunity to build their knowledge via interaction and discussions and through the exchange of educational and research materials sharing of information and educational programs among the students as well as faculty members through the files stored on a storage service in cloud computing like dropbox it benefits their previous experiences and builds on their new experiences through such interactions the nature of services benefits and use of cloud computing makes it imperative that learners play a more active role that a teacher who is just a facilitator many researchers also emphasize the role of cloud computing in the provision of training facilities for the development of scientific innovation skills development of skills and mental capacity besides providing an integrated and flexible teaching system this correlation is best understood from a research by denton that there is a causal relation among constructivism cooperative learning and cloud computing to enhance the instruction steps it becomes possible through the multiplied tools it supports and is consistent with the social constructivism theorys principles in teaching and learning which focuses on the importance of social interaction in the construction of knowledge based on the previous experiences of learners it also supports the importance of education to prove meaningful as well as the importance of learner to be active in their concentrated learning paying attention to the development of mental skills statement of the problem it has been brought into notice above that the importance of integration of technology in general and cloud computing in particular in the universities besides the benefits of services and advantages cant be ruled out it fits well with various theories of learning especially with the social constructivism theory the powell cody study reveals that efficient classrooms depend heavily on the constructivist strategies for cognitive learning today cloud computing services and the nature of their uses supports the foundations of the social constructivism theory where cloud computing introduces educational environments based on teaching and learning which has to take place in the framework of cooperation and social interaction in order to build knowledge and disseminate that to others in turn it helps to develop an individuals intellectual social and scientific skills through the work of this researcher in the field of higher education in the kingdom of saudi arabia it is felt that there is a need to investigate the role of cloud computing for the enhancement of teaching and learning in the saudi arabian universities in accordance with the four principles of social constructivism theory from the point of view of specialists as well as those responsible for integrating technology to support teaching and learning at such universities through the importance of the study there is no dearth of studies on the use of cloud computing in higher education and so are many studies on social constructivism theory too but this study is characterized by a link between cloud computing and social constructivism theory which remains one of the most important educational theories today this study not only investigates the role of cloud computing in teaching and learning in general and in the social constructivism paradigm which has been overlooked by the previous studies especially in the context of saudi arabian universities further the results of this study will contribute to the development of elearning which will help those leading the deanships of elearning and distance learning to develop elearning at their universities by using cloud computing in the social constructivism paradigm moreover this study also helps to clarify the relationship between cloud computing and the social constructivism theory in addition the importance of this study lies in exploring the use of technology including cloud computing and its services to support learning apart from the important role of teaching and learning based on the educational theories including social constructivism theory which provides us with an opportunity to benefit from the technologies in order to support and promote teaching and learning on sound educational principles and foundations 5 research methodology research approach this study was conducted across all saudi arabian government universities in the kingdom of saudi arabia consisting of 29 universities with a quantitative approach based on a questionnaire being used to conduct the study 52 the population of the study the studys population consisted of the deans and vice deans of elearning deanships in all saudi arabian government universities whose total population was 98 represented by both male and female deans and vice deans in the academic year 20162017 the population consisted of the specialists in this area and at the same time those who were responsible for the integration of technology in their respective universities in order to support and promote learning study sample the study sample included the entire study population except those who did not complete the questionnaire with a total sample size of 84 male and female deans and vice deans of elearning deanships as a purposive sample that represented 857 per cent of the total study community 54 the study tool the questionnaire was the study tool paperthe role of cloud computing for the enhancement of teaching and learning in saudi arabian… building the tool of the study after reviewing the theoretical literature and the previous studies pertaining to the subject of this study the researcher built the tool by starting with the preliminary questions about the initial data including participants name university name and specialization which were all optional the four main sections related to the role of cloud computing in order to enhance teaching and learning in the saudi arabian universities based on the principle of social constructivism theory where the first section specific to the principle of social interaction which included 11 questions the second section was about the principle of previous experiences which contained five questions the third section was related to the principle of the activity of the learner which included 12 questions finally the last section was about the principle of the development of the mental skills which contained 7 questions it is worth mentioning that the questionnaire was converted into an electronic questionnaire which facilitated the process of sending the study sample through email and other electronic means of communication in order to assist the study sample to complete and to return the questionnaire quickly and easily validity of the tool the veracity of the tool was ascertained by subjecting it to rigorous scrutiny for revalidation it was presented to a group of experts and based on the feedback suitable modifications were made to make it foolproof reliability of the tool the alpha cronbach coefficient was calculated to confirm the reliability of the tool and as shown in table 1 the tool of the study has a high degree of reliability data analysis the data were analyzed by using the spss program and used the following statistical methods of data analysis • percentages to describe the characteristics of the study sample • cronbachs alphacorrelation to determine the reliability of the study tool • arithmetic mean and standard deviation to order the responses of the study sample when analyzed the responses of the study sample were considered so that if the mean value was • from to the degree of agreement from the point of view of the sample is very little • from to the degree of agreement from the point of view of the sample is little • from to the degree of agreement from the point of view of the sample is medium • from to the degree of agreement from the point of view of the sample is large • from to the degree of agreement from the point of view of the sample is very large this applies to the tool sections which apply to the questions on the questionnaire as in the previous division 6 the results of the study discussion to answer the study questions the researcher calculated the means and standard deviations for the sample responses about the role of cloud computing in enhancing teaching and learning in accordance with the four principles of social constructivism theory statements in table 2 3 4 and 5 shows that ranked descending by mean according to the relative importance of each statement from the samples selfreported perspectives shown as the ratio of the per cent to total number of the sample the role of cloud computing in enhancing teaching and learning in saudi arabian universities in the context of the principle of social interaction selfreported sample on the role of cloud computing in enhancing teaching and learning in saudi arabian universities based on the principle of social interaction table 2 shows respondents feedback on the role of cloud computing in promoting education based on the principle of social interaction the results show that 881 of the study sample endorse that cloud computing offered the opportunity to publish teachers audio and video lessons on students digital devices 917 agreed that cloud computing contributed to the sharing of knowledge the table also shows that 916 and sd059 agree that cloud computing allowed the learners to interact with the course instructors it is worth mentioning that despite the agreement 881 of the study sample agreed that cloud computing helped to use teaching and learning activities for the reallife tasks however it is the lowest compared to the other services and roles provided by cloud computing it is clear from the total mean of the role of cloud computing in enhancing teaching and learning in the saudi arabian universities based on the principle of social interaction is quite large which is primarily owing to many advantages of cloud computing services that support focus of social theory on the importance of social interaction in knowledge building cloud computing provides many advantages and services which support social interaction file and image sharing and helps learner activities and interaction with the teachers and other learners cloud computing provides students with the ability to share teaching and learning materials references research papers and scientific articles to name a few through the files stored on storage services in cloud computing further denton has reported on the positive aspects of cloud computing in education such as trough tools like google docs and microsoft office live which can support teaching methods based on the constructive and collaborative teaching and learning using social constructivism theory cloud computing facilitates easy access to knowledge content and research websites for collaboration and knowledge building enabling seamless exchange of knowledge between the students faculty members and researchers 63 the role of cloud computing in enhancing teaching and learning in the saudi arabian universities based on the principle of previous experience selfreported sample on the role of cloud computing in enhancing teaching and learning in the saudi arabian universities based on the principle of previous experience table shows respondents opinions on the role of cloud computing in enhancing teaching and learning in the saudi arabian universities based on the principle of previous experience the table shows that 809 of the study sample agreed that cloud computing helped to integrate students experiences in acquiring knowledge this may be due to the nature of cloud computing services that gives the users opportunity to build new experiences through their previous experiences the results also show that 774 of the sample believed that cloud computing gave the learners enough time to meditate in the new experiences and that the learner used cloud computing based on hisher own speed and abilities in general the total mean shows larger role of cloud computing in enhancing teaching and learning in the saudi arabian universities in the light of previous experiences furthermore denton reported on the advantages of the services of cloud computing in the education field such as google docs and microsoft office live which have the potentiality to promote and support teaching methods based on the constructive and collaborative teaching and learning by using the social constructivism theory 65 the role of cloud computing in enhancing teaching and learning in the saudi arabian universities based on the principle of activity of a learner 30 and sd060 agree that cloud computing helped the learner to have an active role in the teaching and learning process the results also show that 857 of the sample believe that cloud computing contributes to transforming the role of academic staff from a microcontroller in the teaching and learning process to a facilitator of learning in general it is clear from the total mean that the role of cloud computing in enhancing teaching and learning in saudi arabia in the context of the activity of the learner is significant it may be due to the foundations of most cloud computing services where the focus is on the users playing a significant role in content management and selfreliance in acquiring knowledge and the effectiveness of the learner which is consistent with the third principle of the social constructivism theory where focus was on the activity of the learner in the teaching and learning process cloud computing has many new ways of thinking about various areas such as teaching and learning design teaching and learning experiences interaction and adapting cloud environments to user needs and opening up the potentialities to deliver a common experience which will stimulate new types of requirements needs and user activities 67 the table 5 shows respondents views on the role of cloud computing in enhancing teaching and learning in the saudi arabian universities based on the principle of the development of mental skills the results show that 916 of the study sample agreed that cloud computing contributed to the diversity of access to information the results also show that 833 of the sample believed that cloud computing encouraged focus on skills development more than information transfer also more than threequarters of the sample 786 agreed that cloud computing helped to target higher thinking levels in general the total mean shows a larger role of cloud computing in enhancing teaching and learning in the saudi arabian universities based on the principle of the development of mental skills the study by hussona conducted at alaqsa university which confirmed the effectiveness of cloud computing in teaching and learning and training and for developing skills in the use of cloud computing conclusion this research concludes with the findings and a blueprint for the further research it is clear that there is a very critical role for cloud computing in enhancing teaching and learning in the saudi arabian universities on the lines s of the four principles of social public interest statement cloud computing has become a reality today as far as its uses in the multiple forms are concerned universities and other institutions of higher learning cant ignore the role of cloud computing in the current scenario even as information technology has a greater say in each and every sector this research had been conducted in the context of the saudi arabian government universities to assess the role of cloud computing in enhancing teaching and learning experience in the concerned universities one new dimension being incorporated was the role of cloud computing in accordance with the context of the social constructivist paradigm as seen through a specialist educationalist point of view this research thus brought to fore the relationship between cloud computing and social constructivism theory in the context of the educational system in saudi arabia it will greatly help all the stakeholders in understanding this perspective constructivism theory from the point of view of the specialists who are responsible for the integration of technology in order to support the teaching and learning initiatives in the universities

this study aims to evaluate the role of cloud computing in enhancing teaching and learning in the saudi arabian government universities in the backdrop of the four principles of social constructivism theory social interaction previous experience activity of a learner and the development of mental skills all of them have to be examined form the specialists point of view as heshe will be responsible for integrating technology into the processes to support the whole ecosystem the study was conducted at 29 saudi arabian government universities using a quantitative approach based on a questionnaire the study sample consisted of 84 deans and vice deans of elearning across all saudi arabian government universities in the academic year 20162017 the results revealed a significant role for cloud computing for teaching and learning enhancement in the saudi arabian universities in accordance with the construct outlined above

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i introduction he goal of this work is to explore the role technology can play in alleviating some of the burden placed on social workers and parasocial workers who are attempting to serve the millions of orphans and vulnerable children across tanzania 1 specifically we explore the use of sms to improve the cost regularity and timeliness of reporting data to the relevant government database so that resource distribution can be better informed and services provided to ovc can be enhanced a background as of 2007 an estimated 33 million people across the globe were infected with hiv 2 prevalence of hiv among adults in tanzania is estimated to be 62 that is an order of magnitude greater than prevalence in the united states 1 hiv renders people more susceptible to infection so exposure to these diseases increases the likelihood that hivpositive tanzanians will develop aids in 2007 alone tanzania reported approximately 96000 deaths due to hivaids furthermore tanzanians are at a high risk of contracting other infectious diseases such as hepatitis a typhoid fever and bacterial diarrhea adult mortality in tanzania has left approximately one million children parentless and in a vulnerable position 2 the hivaids twinning center estimates this number is even higher and reports that nearly 25 million tanzanian children have been orphaned or made vulnerable by hivaids and the number is expected to reach four million by 2010 if effective prevention and treatment measures are not implemented 3 poverty is a factor that further cripples those afflicted by hivaids according to the world bank 36 of the tanzanian population falls below the national poverty line 4 economic hardships exacerbate the hivaids epidemic by limiting the healthcare resources accessible to patients the social stigma concerning hivaids is an added burden borne by tanzanians who contract the disease and this stigma often extends to the relatives and associates of the hiv infected tanzanians hence fear of being ostracized deters many tanzanians from getting tested for hiv and contributes to the continued spread of the disease due in part to this spreading epidemic tanzania faces a severe shortage of trained social workers particularly to provide services to affected individuals some of the factors escalating the need for social workers in tanzania are the increasing number of hivaids adult deaths the concurrently rising number of ovc and the breakdown in family support structures due to greater migration from rural areas to cities 5 although need is abundant human and financial resources available to social welfare groups attempting to address these challenges is limited b parasocial workers tanzania needs at least 8000 additional social workers according to the countrys institute of social work to meet the current demand for services to address this challenge several groups in tanzania are involved with training thousands of parasocial workers to provide services to hivaids victims and their families especially to ovc many of these psws are already community development officers or representatives of communitybased organizations 5 an estimated twothirds of tanzanias 127 districts are left with no social welfare support due to a lack of trained welfare workers 5 thus in 2007 the hivaids twinning center joined with isw the university of illinois at chicagos jane addams college of social work and the midwest aids training and education center to launch their parasocial worker training program this program was designed to arm communitybased caregivers with critical skills needed to help improve the lives of orphans and vulnerable children 6 at the time of this work through their efforts these organizations had trained 516 psws 40 district social workers and 55 master trainers in tanzania 6 the newly trained psws are identifying new children and families in need and connecting them with critical support and assistance 6 home visits are conducted to gather information on the children and their current situation however the supply of social workers still falls short of the number needed to reach all ovc around the country c supporting efforts in addition to the ongoing work by psws social welfare organizations such as huyawa the institute of social work and wamata provide ovc and their families with school supplies counseling services and advice on a range of life skills such as caring for family managing with a small budget as well as family planning and hivaids prevention 5 furthermore there is a national effort to monitor and evaluate hivaids data in tanzania by way of the tanzania output monitoring system for hiv aids this national system is dedicated to collecting information on the impact of the disease in tanzania which includes data on ovc the department of social welfare a governmental organization maintains a database specifically on ovc the goal for this database is to enable leaders to make more informed decisions on how to combat the spread of hivaids in the country and to allocate limited resources more effectively however psws usually receive no compensation for their work and therefore do not generally have incentives to collect or submit high quality data to the dsw database 5 6 er2008001pdf in summary while psws carry the primary responsibility in providing essential services to the growing population of ovc in tanzania they are often not paid for this work and are unable to access governmental resources due to the lack of an effective means of reporting needs and relevant information to the national database on ovc in a timely manner we worked with several relevant groups in tanzania to understand the needs of this community and based on these assessed needs we proposed a smsbased solution to address the reporting challenges faced by the psws this paper reports our needs assessment process reviews the related work describes the implementation and pilot testing of our solution and concludes with a discussion of future work that could further enhance this solution ii needs assessment our needs assessment process informed us of the challenges faced by the social worker community in tanzania their desired solutions and the existing infrastructure that has been created by associated organizations to support them to gather this information we identified two community partners who could assist us with our needs assessment process and also provide us with valuable feedback on our developed solutions our first partner was the institute of social work an academic institution that works with several partners to train psws as well as the trainers of new groups of psws through programs throughout tanzania our second community partner was the department of social welfare a government office which currently maintains a national database of ovc initial meetings were held with several local organizations that conduct or oversee social work isw houses a program for supporting ovc which started in october 2006 and is sponsored by usaid at the inception of the program they trained community members who already work with ovc in order to empower and motivate them to continue to provide services to the ovc after a social worker symposium a curriculum was developed for training supervisors who then go on to train psws isw partnered with the jane addams college of social work at the university of illinois at chicago in the united states to deploy the train the trainer approach through this partnership isw has been able to train several hundred psws under the new curriculum the psws are all trained in their respective districts with an emphasis on methods for identifying ovc and a standard process for collecting data and providing services several groups helped us to better understand the data collection process for the national database at the wamata nonprofit organization that was the first hivaids support organization of its kind the staff members explained that a major challenge is keeping records and tracking the ovc the ovc data management specialist at dsw stated the major issues that their institution faces with the data collection for ovc was incompleteness of and inaccuracies in the data at the time of this work out of a total of 132 recognized districts 81 reported to the national database while 51 did not submit any information those that reported often did not send complete information additionally information verification occurs through a manual checking process conducted twice a year if the national database received information electronically and more frequently than every three months the entire process of data collection and verification could be streamlined a psw interviews and observations we interviewed five psws all from the dar es salaam region which contains three districts kinondoni ilala and temeke many of these workers are involved with the village or ward committees that provide data on ovc to the national database and would therefore be the end users of the proposed technology solution we also conducted a site visit to tandika village which is located in the temeke district our interactions with the community in the tandika village provided us with a firsthand view of the problems that the village members face on a daily basis the interviews with the psws revealed that lack of resources and incentives were major obstacles to comprehensive data collection the psws were able to give us a grassroots perspective as to why the data does not get to the various levels of government as fast as it is needed psws focus on meeting the daytoday needs of the ovc and other community members and often do not have the time or resources to submit paper reports they also find that sending in reports to the district level governing body yields little in terms of support or resources instead the village committee must find the resources to provide ovc with essential items such as food health care school supplies and clothing apart from this printing photocopying and travel expenses required for preparing and submitting reports are costly especially if there is no assurance that the district will compensate them for these costs furthermore there is no official at the district level who advocates for providing funds and resources to social welfarerelated work finally although the psws receive some training they often do not receive support beyond that initial instruction many of them are not paid for the social work services they provide they perform social work on a voluntary basis and maintain other jobs to earn a living the interviewees were schoolteachers cooks electricians program coordinators at nongovernmental organizations and chairmen of their village committees b data collection challenges at our initial meeting with partners we found out that data transfer from the ward level to the district level is very slow dsw in tanzania collects data from village ward and district committees currently this data collection occurs via paper forms and as such it can take a long timeon the order of monthsfor the forms to reach their final destination the national database specifically reporting is a multistep process involving paper forms sent to the district where they are digitized and forwarded to the national database psws predominantly operate at the village level their efforts are concentrated on serving villages and the reports they construct are brought to a ward a ward is a collection of approximately three villages where the social workers can meet and interact as visits to the ward happen very frequently if not daily at the ward level the paper reports are collected and then are taken to the district level this process is rare and expensive the bus ride into the district can take hours and is often uncomfortable and costly at the district level the forms are digitized and submitted to the national database once every three months however the many difficulties of wardtodistrict transportation can cause the forms to be delayed anywhere from a couple of months to a year in addition to some forms being lost entirely this in turn leads to the national database containing outofdate and incomplete information there are two main issues with this data transfer 1 lag time to transport the paperwork and 2 misplaced or lost documents during this transfer approximately 60 of districts send in reports to the national database and only a handful of those reports are complete the omissions and flaws in the reporting process hinder the flow of communication government officials and donors use this information to make critical funding and policy decisions therefore it is important to obtain accurate data so that adequate resources are provided to support services for ovc c proposed solution based on the findings of our needs assessment we proposed a technology solution that could address the reporting needs of the local social worker community this solution was iteratively developed utilizing feedback from our community partners and led to the production of our smsbased solution the scope of this project was to test this prototype by ascertaining its potential to be deployed adopted scaled up and sustained in tanzania to this end we obtained relevant user feedback and also proposed a deployment strategy prior to developing our solution based on the needs identified with our partners we surveyed related technology solutions to inform our solution design iii related work the problem of exchanging information without advanced infrastructure such as internet access stable mobile phone connections or landline telephone service is a problem occurring throughout a variety of different ictd projects due to the prevalence of this problem a variety of research groups and other organizations are working to improve information exchange in rural areas a voicebased solutions several research efforts have explored voicebased information retrieval systems relevant to developing community settings one example is healthline which is a speechbased system that allows users to access information from a database via a phone call 7 there are several advantages to a speechbased solution first such systems do not require high levels of literacy and only call for a low level of technical skill moreover all data processing and custom software is serverside eliminating the need for any installation on users phones however this work does not address data entry which is an essential component of our project 7 3 our works is targeted towards reporting rather than retrieving information this can be a relatively expensive process via phone call and hence is not feasible for our target users similarly the tracnet system in rwanda was designed to collect store retrieve and disseminate a variety of information related to hivaids care and treatment 4 the ministry of health and the treatment research and aids centre joined forces to deploy tracnet to increase the efficiency of rwandas hivaids program management and enhance the quality of patient care tracnet has been deployed nationwide to connect every health facility providing hivaids treatment and related services the primary mode of information exchange in tracnet is a bilingual english and french telephone and web interface the backend of tracnet is a central information repository the system has reportedly transformed a largely paperbased one way information flow that took several weeks into a bidirectional data exchange completed in seconds hence it allows decisionmakers and supervisors to quickly analyze and respond to program information ugandas rakai center and others are utilizing similar systems to enhance information management and treatment provided to hivaids patients 8 however none of these systems have explored methods for reporting information in settings where phone calls are costprohibitive in working with psws in tanzania who have very limited income and who were unable to afford phone calls or internet access for regular reporting of ovc data we had to explore alternatives solutions patnaik brunskill and thies presented a review of accuracy rates of different data collection mechanisms using mobile phones 5 their study compared three different methods utilizing a java application to enter data into a form sending a coded sms message and verbally reporting information to a human operator via a phone call in comparing these three methods they tracked mistakes that workers made as well as the duration of the interaction the results showed that the sms and java application methods had a comparable error rate the voice solution however produced errors less than 05 of the time the duration of an interaction using sms and the java application was also close while interactions on the phone took almost one minute longer in exploring alternatives to voicebased solutions which were costprohibitive for our targeted users this study was useful in understanding the accuracy rates of alternate communication methods b sms solutions frontlinesms is a project that was developed to encourage stronger communication for nongovernmental organizations and their workers the system provides a suite of tools that only requires a computer and a mobile phone it can then arrange text messages such that they can be sent either to individuals or to large groups and conversations can be organized 9 it has been used in a variety of projects including in a hospital in malawi where it was able to track patients respond to requests for care and answer health workers queries for dosage information 10 however frontlinesms is not open source and is better suited for connecting and tracking field work the goal of our project was to automate the data entry and provide confirmation that the reported data reached the database frontlinesms does not allow users to export and automate the process of data and therefore was not as useful for our target application texas a m university implemented the links project in 2004 in kenya and ethiopia links which stands for livestock information network and knowledge system allows users to send coded sms messages to a central server 6 these sms messages contain data such as livestock type age and condition and the server will reply with a sms message containing the prices a farmer could receive for such an animal in different nearby markets this enables farmers to maximize their profits and thereby improve their livelihood the links study emphasized that using coded text messages is a feasible way of interacting with a system in the context of ictd work this system was the most promising solution for the constraints of our target application and hence the links protocol informed several aspects of our solution design c other relevant tools the openrosa consortium is a group of developers working to create open source protocols for data collection on mobile devices through projects such as javarosa openrosas standards have been used to develop mobile phone applications in developing communities 7 11 projects using the javarosa platform can be run on most javaenabled phones including the nokia 3110c and 6085 which are readily available in lowincome regions 8 however despite being available java compatibility is neither universal nor cheap since mobile phone customization is relatively uncommon in tanzania this may lead to a number of issues especially concerning usability as the psws did not seem to know how to use java applications in contrast the psws were very comfortable using sms epihandy is a suite of tools constructed with openrosa for data aggregation on mobile phones it includes a wealth of already developed tools both userand serverside to run on smart and javaenabled phones that would minimize the need to reimplement basic data collection functionality epihandy includes tools to design user interfaces that make data entry more user friendly 9 12 but also requires a consistent connection for data collection 10 additionally the storage of data on memory cards raises the cost to ensure that data is not lost before it is transmitted and privacy becomes a concern in the event that a mobile phone is lost or stolen cambrowser is a solution that targets formbased data entry utilizing the cameras that are becoming more prevalent in mobile phones cambrowsers developers hope to make data entry more efficient to enter data users have a copy of a paper form listing all the fields and a corresponding bar code for each field to enter data into a particular field they take a picture of the bar code and cambrowser is able to decode the image to ascertain the type of data the user is entering thus ending the need to navigate through menus 9 10 11 12 11 cambrowser offers an alternative to cumbersome navigation menus or text coding that is valuable for lowliteracy users however for our work the users were literate and given the complexity of implementing cambrowser we decided that the cost outweighed the benefits additionally mobile phone cameras are not universal and hence an application that requires a camera would limit the number of users that could be served none of the related work surveyed addressed the need for effective processing of reports at the ward level as well as the need for the application to be cheap and easily deployed on a variety of mobile devices thus we decided to develop an application specifically for enabling psws in tanzania to report vital information on ovc more easily and quickly iv implementation details our needs assessment process revealed that the psws need a less complicated and less costly method for submitting reports if they are to submit data more frequently and consistently all of the psws we interacted with own basic mobile phones and use their phones on a regular basis typically every day in contrast none of them had easy access to a computer as a result we decided to focus the project on developing a mobile phone application that would help social workers and psws transfer relevant summary information more regularly into the dsw database in tanzania sms is much more affordable than phone calls the cost of a mobile phone call per minute can be as much as five or six times the cost of sending one text message 13 therefore a smsbased solution would be a less cost prohibitive mode for transmitting data although a smsbased technology solution is limited by the character allowance in a text message our community partners identified the following key pieces of information that can be submitted in aggregate form via a sms • number of ovc • gender and age breakdown of ovc • location of ovc • needs of ovc and services provided to them a information flow informed by the assessed needs of the psws the primary goal of our project is to digitize information at the ward level as illustrated in fig 4 we targeted our efforts towards streamlining the process of data transfer out of the ward directly to the national database in doing so the lengthy and arduous task of transporting a large number of backlogged paper forms to the district level at uncertain intervals could be minimized and the national database could be updated directly from the ward level due to the limitations in the volume of data that can be transferred over sms it is infeasible to digitize all data at the ward level using the proposed approach hence this system does not entirely eradicate the need for paper forms however it does allow the national database to be updated with key information at more frequent intervals b sms solution tradeoffs sms is a lowcost lowbandwidth method of transmitting data that is supported by most mobile phones in particular we found a smsbased solution most appropriate because many users already own mobile phones and the cost of an individual sms is very low additionally owing to the fact that sms is considerably less expensive than standard voice communication many tanzanian mobile phone users are already familiar with sms we explored several other options before ultimately settling on a smsbased solution a voicebased system where users dial in to a call center and speak to a live operator who then enters the relevant data is highly robust this method avoids the possibility of mistyping data and allows for instant clarification of information and collection of a greater volume of data additionally a voicebased option was shown to have lower error rates than sms and mobile phone applications 5 however the high cost of airtime compared to sms as well as the additional cost imposed and time required to train and employ phone operators dissuaded us from pursuing this solution path we also investigated the possibility of using a mobile phone application to help users format their responses properly our hope was that this would decrease error rates by making data entry more intuitive however previous ictd studies have shown that error rates were not significantly different between data entered with the aid of a java application and handformatted sms 5 each of the application formats we considered posed significant barriers to widespread deployment java applications tend to only run on higherend mobile phones and sim card applications require approval from network operators therefore we designed a system that uses handformatted sms messages to transmit data we employed a key code style format sms message similar to the one used by links 6 as illustrated in fig 5 social workers are given a small card which contains all of the codes to be used in the sms message this sms message is then sent to a central server which takes the information and process it into the national database c system components we decided to implement the server using several open source technologies kannel14 python and zope kannel is a sms gateway which serves as the connection between the mobile phone networks and the server connecting one or more gsm modems to zope zope is a web framework written primarily in python our decision to use zope was motivated by a need to design a simple and intuitive administrative interface as well as work together with kannel and external databases for database connectivity we used sql alchemy15 an object relational manager for python which easily allows us to plug into various backends presently our development version of the server runs using sqlite however for larger scale deployment a better choice would be a production quality database such as mysql or postgresql we designed the system to receive text messages through the sms gateway kannel by connecting a phone or gsm modem to a computer kannel receives sms messages from the phone processes the information into an xml file and sends it to a zope application zope is a content management system that has been in development since 1995 using an array of zope modules an application was developed that stores the received sms messages in sql by parsing the xml file for the required fields 16 if the zope application finds the message to be improperly formatted or having anomalous values zope returns an error to kannel which replies the user with the problem zope encountered following this process the user can remedy the error and resend the information which can then be submitted to the national database in our solution design users are given instructions on how to format a special sms containing data they have collected in their work with ovc shortly after a user sends this sms to the supplied numbera phone number that would be owned by the server operatorthe server receives parses and automatically enters it into a database the server is also able to determine from the sms which user sent the data and the region where he or she works server administrators can export and analyze the submitted data as they choose userside data flow begins with the usersin our case the psw or social worker users are instructed via cue cards to submit data by sending a specially formatted sms this technique of using cue cards has been shown to be effective in a previous ictd study 5 still despite its many advantages sms has its drawbacks a sms is limited to 160 characters and the lack of a proper keyboard on most phones makes typing large amounts of data cumbersome and errorprone thus it is reasonable to expect users to be able to accurately enter no more than a small amount of numerical dataa total of approximately 10 to 20 characters based on discussions with personnel at our partner organizations we determined that the most useful data would be summary data such as the number of ovc identified in a village their gender breakdown their age range as well as which services are currently best provided and which services are most needed such data is expected to allow an administrator to identify meaningful trends in social work across the nation and enhance the input of data to the national database each sms begins with a personal identification number that uniquely identifies the user combined with user registrations in the database the pin also allows the server to identify where the data is coming from as each pin is tied to a specific village users can either register via sms or can be manually entered into the database by an administrator serverside within minutes if not seconds of a user submitting a sms the server receives the message this is accomplished using kannel in conjunction with a gsm modem since the format specified by the cue cards is machinereadable as soon as the server receives a sms it is parsed and entered into the database in the event that the server receives an incorrectly formatted message or one with clearly incorrect data instead of entering incorrect data into the database the system flags the message for review by a human operator in particular messages that cannot be properly parsed are flagged and depending on the data we could implement rangevalidation as well which will only allow specific reasonable ranges of values for different fields this system combines the benefits of the robustness of a human operator when needed with those of digitization v prototype testing after developing a prototype technology and cue card system we conducted an initial evaluation to gauge the usability and feasibility of the proposed technology this was done in two stages • stage 1 determining deployment potential of the mobile phone application by demonstrating the solution prototype to partner organizations to obtain their feedback • stage 2 assessing feasibility of cue card instructions with a village ovc committee to understand the degree to which they can follow the instructions to send sms in the required format a feedback on technology demonstration our technology demonstration resulted in the following feedback about the technology • highlighting errors in data records for human intervention is very useful • the limitation on the amount of data that can be sent via sms is a concern currently they use paper forms to send a lot more textintensive data such as comments on particular children and other problems in the community it is not feasible to send such data in one sms message • training people to send data using this technology could be challenging because many people in villages and wards have limited exposure to technology and some do not even own or use mobile phones • lack of mobile phone network coverage in certain areas of the country will be an issue for a smsbased solution • since there are up to 12000 villages in tanzania we need to make sure there are a corresponding number of unique pin codes to assign to data senders at different locations this feedback was useful in understanding some of the obstacles we would face when deploying a largerscale phase of the project since the feedback about the technology itself was positive the demonstrations did not lead to further modifications of the solution at this stage however it did help shape the instructional cue cards as well as the deployment strategy for this project b psw feedback on instructional cue card system the instructional cue cards designed for data senders were tested on five ovc committee members from tandika village for this testing we provided each of them with a cue card which contained the following instructions translated into kiswahili we asked the psws to imagine they had 11 ovc in total of which six were female and five were male equipped with this information and their mobile phones we asked them to try to follow the instructions and transmit the data provided the mobile phone on the receiving end of the sms data was one of the researchers personal phones this allowed us to verify the accuracy with which the psws formatted and submitted the given data there were several useful observations that resulted from this trial • participants had a difficult time understanding step 2 of the cue card instructions they asked for some guidance for this and were subsequently able to send the sms in the required format • none of them knew what numerical input mode meant so we needed to show them how to access it on their phones so they could follow the instructions • it was clear that three of the five ovc committee members were quite proficient in sending sms with their phone and mastered the instructions very quickly the other two committee members had a difficult time getting past instruction 2 • one of the members had little to no experience with sms and required guidance through the entire process • we received correctly formatted messages from three of the members a fourth member formatted it correctly but didnt wish to send the sms the fifth member did not successfully format or send a message • we noted that the committee members worked together to assist each other with the task so with more time they are likely to help each other be able to send correctly formatted sms • the participants said that the instructions were not difficult to follow except for step 2 they also mentioned that they think such an application will be useful to them in their work and that they would use it if it were available c key challenges and limitations there are a number of challenges inherent to the problem of transmitting ovc data in tanzania to a national database chief among these is costs once the server is set up the cost per data submission will be just the cost of one sms at the time of this publication the cost of sending a sms was roughly equivalent to the cost of making a photocopy which is currently necessary for the psws to submit the paperbased forms although we believe mobile phones can be an effective tool in a wide range of data transmission applications including this one there are a number of limitations to the platform worth noting more remote areas in tanzania where data collection is already challenging may have little or no mobile phone reception thus our system is designed to complement rather than replace the existing system of paper form transmission however the spread of mobile connectivity is likely to address this challenge in the near future furthermore mobile phones are not designed as generalpurpose data entry devices and so they run into usability issues entering data via the keypad particularly alphanumeric data can be difficult and error prone d deployment considerations during the last week of our field research in tanzania we worked with our local partners to come to an agreement on what the next steps of this project would be we agreed to continue communication with dsw through their data management specialist furthermore we will work with dsw to come to an agreement on ownership of the application and a plan for future deployment of the project we are also interested in helping isw to explore other uses of the application that can benefit tanzania such as designing and implementing a system to help monitor the psw training program and collect statistics on the spread of diseases psws were given the opportunity to learn about the technology and provide feedback on the instructional cue cards apart from this we committed to keeping them apprised on the progress of the project via isw the sustainability of this project relies heavily on a local party taking further ownership of the application and hosting it on their server the ideal candidate for this role would be dsw once ownership of the technology is undertaken by a local partner we can work with that group to plan further testing as well as a longterm study to deploy collect data and evaluate the effectiveness of this technology solution vi conclusions and future work in this work we show that a smsbased data transmission system can be feasibly implemented within the social worker community in tanzania however several steps need to be taken to build the human resource and government advocacy infrastructure that would be necessary in order to successfully deploy this system the smsbased technology will help supplement the current paper form method for data collection within this community while improving the efficiency and timeliness of transmitted data additionally the affordability of sms compared with alternative avenues for information communication render this approach more feasible to and adoptable by the end user the psws at the ward or village level in future work we also plan to enhance our system given further feedback and begin deploying the application in a relatively small trial potentially in the dar es salaam region to accomplish this deployment we would need further cooperation from dsw which is officially in charge of social welfare programs within tanzania during this trial we will collect further feedback on the application and iteratively improve and expand the technology additionally we intend to focus on establishing local ownership of the project and infrastructure for broaderscale deployment we anticipate that the application could easily grow to cover the entire social welfare network of tanzania in addition to further testing and implementing this solution there are a number of interesting technical areas where our work could be extended two interrelated ideas we would like to highlight are servertouser communication and timesensitive surveys servertouser communication would allow server administrators to contact users via the same mobile phones they use to submit data there are some issues with this including the bandwidth limits of a gsm modem the possibility that such communication is unwanted by its recipients and of course additional costs that said by initiating twoway communication valuable new possibilities emerge one such possibility is a method for collecting timesensitive surveys a survey could be distributed via sms and then collected via sms with a response time that would theoretically be in minutes again there are challenges involved in implementing this particularly regarding usability but it could prove a versatile and useful tool some possible uses could include tracking the spread of diseases or in disaster monitoring another area we hope to explore is generalization the project generally solves the problem of submitting data especially locationtied data to a database this has many possible applications beyond the scope of collecting data for social welfare in tanzania 1 2 nzaniaasp 3 4 t

although parasocial workers carry the primary responsibility in providing essential services to the growing population of orphans and vulnerable children in tanzania they are often not paid for this work moreover these parasocial workers are unable to access governmental resources due to the lack of an efficient means of reporting their needs to relevant government officials in a timely manner in this paper we describe a text message sms based solution that harnesses the prevalence of mobile phones coupled with several open source tools to empower these parasocial workers specifically we build a more efficient mechanism for reporting summary data on orphans and vulnerable children to relevant government officials in a costeffective and efficient manner this paper reports on our needs assessment process reviews the related work describes the implementation and testing of our prototype solution and concludes with a discussion of relevant future work

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background khat refers to the psychoactive leaves and shoots of the shrub catha edulis 1 fresh leaves of khat contain the amphetamine like stimulants cathinone and cathine which are extracted by the action of enzymes in saliva khat cultivation is more common in eastern africa and the arabian peninsula 23 khat is believed to be native to ethiopia and was introduced to yemen between the first and sixth centuries the chewing of khat was recorded in the chronicles of the ethiopian king amda seyon 4 catha edulis has various local names khat qat chat or miraa tea of the arabs or abyssinian tea in which the dried leaves of khat were boiled and used as modern tea 5 cathinone found in the fresh leaves of khat and cathine are the main active ingredients of khat although over 40 compounds have been identified in khat extract 67 the pharmacological effects of khat chewing were analogous to those of amphetamine and cathine and cathinone were assessed as meeting the criteria for control under the convention of psychotropic substances and recommended for scheduling 8 the reported psychiatric adverse effects of khat use were depression insomnia suicidal ideation feeling of anxiousness and irritability insomnia loss of appetite nausea and vomiting difficulty of seeing at night headache fast heart rate difficulty with balance and coordination blurred vision difficulty in concentration numbness and central nervous system deficits than nondependent chewers 9 10 11 12 over signs and symptoms there are also psychiatric disorders which were linked to khat chewing 1314 including personality disorders shortlived schizophrenia like psychotic illness mania and more rarely depression 1516 however lack of good data to support the link between khat use and any of the major psychiatric disorders has been highlighted 17 regarding the physical adverse effects of khat the who expert committee on drug dependence and others had reported cardiovascular respiratory and gastrointestinal system adverse effects 618 in addition to its negative health impacts khat use has also adverse social consequences evidence relating to links between khat and loss of relationships has been generated largely through qualitative studies for instance loss of relationships with children and weakening of family relations even when the use was considered socially acceptable has been reported 19 daily users of khat also consume large fraction of the family budget and khat is purchased at the expense of other important family items such as meat and fruit 20 the study found out nearly 16 of the family income is said to be spent on khat and many families do worry about the amount of money spent on khat particularly in ethiopian context khat chewing was practiced by older men in areas where islam religion was dominant during this time khat use had been embedded to culture and practiced as a social custom and like other countries 21 the pattern of use was also for concentration during functional purposes and praying 22 through time the demand increases along with khat cultivation in different areas of the country and it becomes practiced by youth and females as well in the present times different groups of people use khat to increase performance at work including academic tasks to avoid unpleasant feeling peer pressure socialization and when they have petty time 22 23 24 25 the current prevalence of khat use varies from region to region as determined by its cultivation accordingly in the northern part of ethiopia tigray regional state where cultivation is not common the prevalence of use is the lowest and the highest was reported from harari eastern part of ethiopia 22 among high school and college students the prevalence extends to 649 26 in addition to muslim religion and male sex khat use is also associated with alcohol drinking and cigarette smoking 22242527 cigarette was mainly abused to maximize the stimulation power of khat and alcohol is practiced to break the aftereffect of khat generally some of the studies focus on the potential negatives of khat use and others emphasize the benefits of khat what exactly constitutes problem khat use is poorly defined and poorly investigated although there are several studies looking at the potential negative consequences of khat use what constitutes harmful khat has never been explored meaningfully most reports focus on prevalence of khat use without defining what the prevalence represented additionally more focused proposals and explorations of targeted interventions could not be carried out if we do not have established methods to identify people who are problematic users the main aim of the current report is to define what constitutes problematic khat use among khat users in addis ababa ethiopia methods study design the research employed a mixed method exploratory sequential design in the initial qualitative phase of the study we carried out an indepth exploration of the behavior of khat use and what constituted acceptable and problematic khat use based on this exploration it was possible to establish an emic construct of problematic khat use in the quantitative part of the study signs and symptoms considered to be indicators of problematic khat use during the initial phase were combined with signs and symptoms of stimulant use according to the international definition of the dsm5 to assess the pattern of problematic khat use among khat chewers the qualitative method relied on a phenomenological approach with limited ethnographic exploration both indepth interviews and focus group discussions were employed the quantitative part of the study relied on crosssectional assessment of users participants and sampling eleven khat users and two family members of khat users were selected for the indepth interview four focus group discussions with nine khat users in each group were also conducted one fgd was composed of female respondents and 102 participants participated for the quantitative part of the study the participants for both qualitative and quantitative parts of the study were recruited purposively they were recruited from khat markets and khat cafes finding female khat users was very difficult because it is not customarily for a woman to buy khat publically and chew in khat cafes therefore we make snowballing through the process of data collection those participants with better knowledge about khat use behavior were participated in the fgd the study was conducted in addis ababa ethiopia in 2014 data collection methods indepth interviews and fgd were conducted by using semistructured interview questions and topic guides the qualitative study identified the key indicators of problematic khat use these indicators were compiled into a checklist this checklist was supplemented by items from the dsm5 indicators of stimulant relateddisorders if there were any additional symptoms or behaviors that were not mentioned by the participants during the qualitative study the checklist which was developed through the initial qualitative study was surprisingly similar to the dsm5 indicators of stimulant related disorders and only few additional items were included from the dsm5 kessler psychological distress scale oslo social support scale fast alcohol screening test and list of threatening experiences were used to assess psychological distress social support harmful drinking and threatening experiences respectively data analysis audio taped indepth interviews and focus group discussions were transcribed in to amharic the official language of ethiopia data were coded and thematically analyzed the quantitative data were analyzed using simple descriptive summaries frequency percentage and mean of various factors and outcomes a nonparametric test called mannwhitney u test was used to analysis the difference in psychological distress social support harmful drinking and threatening experiences between high risk and low risk groups of problematic khat users mannwhitney u test was selected because the sampling technique was not probability and normality was not assured the statistical package for social sciences was used in analyzing the data ethical consideration the study was approved by the ethics committee of the school of psychology addis ababa university a support letter was also written by the school of psychology all personal identifying information was not processed for data analysis data collection was conducted confidentially after obtaining informed consent which also included consent for the digital recording of interviews for those who participated in the qualitative interviews results acceptable khat use qualitative results seven women and 27 men participated in the fgd and 13 participants were also participated in the indepth interview the majority of the participants age was between 32 and 40 years most had at least high school diploma only four were unemployed respondents associate the acceptable practices of khat chewing with sociocultural functional and medical benefits functional and sociocultural acceptability of khat use although all the respondents did not agree that there is acceptable khat use all agreed that khat has been useful for improving performance in specific tasks comforting mourners and to making joyous celebration in weddings khat was assumed to be the most important agent for socialization and social group formation it was argued that in some societies where khat uses is more common like harar in the eastern part of ethiopia people chew in social groupings and they share different life concerns during chewing sessions respondents have also used khat to alleviate pain female discussants reported the practice of drinking aweza to induce abortion the following quote is a summary of the acceptable use of khat in my opinion if khat is chewed for a specific purpose i do not think it is a problem if i chew khat for praying it is not a problematic khat use and it is also normal using for social life wedding condolence idirafosha and other social gatherings and when another respondent reported the socialization issue people in harar usually chew khat at verandah with groups since the weather is hot the groups of people that are gathered for chewing are called jema and afosha the khat session starts 1200 am and ends as members interest and they chew khat turn by turn at members house unacceptable use of khat respondents advised to limit the amount of khat used the frequency of use and the type of khat depending on the experience of person using khat and other personal characteristics concerning the frequency khat should be chewed less frequently and in variable intervals the respondents explained that for better functionality the amount should be managed and they condemned adventurous chewers who chew more than a bundle just merely to show off or inflate them or to pretend to be rich respondents also admonished that khat should be chewed in the afternoon morning sessions are not advised and not acceptable respondents including women users themselves said that it is not acceptable for women and children to chew khat although women and children chew khat it was not frequently observed when they buy khat or holding khat publically in addis ababa men respondents worried about the rapid increase in the habit of khat chewing among women and high school students it was not recommended and not acceptable for men and women to chew khat together because from their experience when both sex chew khat together they tend to engage in unplanned and risky sexual intercourse especially among the young problematic use of khat problematic khat use was described in terms of quantity of khat used amount of time spent in using khat the immediate and longer term effects of use and in terms of effects of cessation of use quantity of khat used through time to get the stimulating effect of khat users either increase the amount of khat they chew or use additional stimulants like caffeine and nicotine another indicator of taking an increased amount of khat was chewing the geraba and poor quality khat almost all of the respondents agreed that if we have money we always want increased amount and quality khat too much amount of khat is best understood in terms of increasing the amount of khat through time time spent on the behavior respondents blame khat for the amount of time needed to engage in the chewing behavior and for the behaviors which occur following the chewing sessions here what one respondent said is instructive khat kills your time while chewing but waiting for the session of chewing also kills you another respondent also confirmed this by saying as far as my experience is concerned if someone chews in scheduled time that will be no problem but as of me there are individuals who are not khat addicted the most problematic users were those who chew the whole day starting from morning which they term as yejebena through noon ayreand in the night katira the purpose of chewing in the morning is to open their eyes and to stay alert those who chew the whole day or night are ignoring other important duties of life feeling high feeling high was defined by the respondents as distressing overstimulation which is beyond the control of the user during mirqanna state there are different signs and symptoms that cause significant subjective distress or impairment in occupational social and other important areas of functioning even if they want it to be euphoric the reported symptoms of mirqanna were dilated pupil feeling uneasy internal fear involuntary movements of lips hands tongue or mouth which the individual cant control and feeling restless and taking long walks without apparent purpose increase in goal directed activities such as extravagancy urgency for sex and drinking alcohol doing or planning unachievable tasks some chewers may be mute while others become talkative with flight of ideas they get easily annoyed fearful or cheerful cognitively what is expected and acceptable is improved attention and concentration but respondents also reported experiencing exaggerated attention and recall of information which may lead to confusion physiologically increased body temperature and pulse rate were experiences which occurred during and immediately after chewing khat other complaints of chewers were perceptual disturbances for instance they feel easily frightened by insignificant external stimulus especially sound and touch another was being hypervigilant others reported perceiving a sound to be too near when in reality it is very far confusion and poor recognition of familiar environment which occasionally resulted in car accidents was also reported by khat users as a consequence of the mirqanna moreover misinterpretation of external stimulus was also reported here are statements from the respondents in a taxi or a bar i am frightened to express what i want because i believe that they know that i chewed khat and they might think that i did something wrong or committed a crime when people talk to each other i take it as if they are talking about me i also excessively fear when my phone rings i cant talk i hear the voice in the left side when someone is in fact speaking to me from the right side i feel disturbed when socks fall from the rope the socks were hanged from outside home while i am in my bed whenever i chew i will be tormented by insectslouse in my bed during sleeping but this does not happen if i didnt chew my wife also confirmed that the bed was clean and free of insects the above behavioral effects depend on the individual and the type of khat these behavioral and physiological changes are managed normally through chebsi most respondents drink alcohol for this purpose and others perform risky sexual intercourse religious chewers especially muslims reverse the aftereffects by drinking milk those who havent money to reverse the mirqanna through chebsi were the most affected by the unwanted signs and symptoms withdrawal experiences of khat use users of khat reported different withdrawal signs and symptoms of khat these signs and symptoms occurred when users stop their use and or when they reduced the amount of khat they use most of the time the users experience withdrawal symptoms close to the time of their regular time of use the reported withdrawal experiences were increased appetite increased sleep yawning decreased energy irritability loss of motivation and concentration restlessness craving depressed mood and unpleasant dreams in order to manage these withdrawals some respondents chew khat in the morning which is named yejebena others who didnt chew in the morning did not chew in order to save their money for the afternoon khat session and not because they did not experience withdrawals these users try to manage the withdrawal symptoms in the morning by taking excess caffeine and smoking cigarette here are two respondents experience of withdrawals the behavioral effect which is experienced by users as a result of decrease in the amount of khat is called wesewase the term wesewase is also used to describe the state of craving when one sees some cues of khat use such as seeing khat leaves one respondent said you cant always get money for khat regularly by this time you are forced to divide up the existing amount of khat or if you are chewing being in jema what you have to do is mefalate which means chewing speedily but in all circumstances you will be at wesewase this is typically observed when guests join the khat session without having their own share i desire to stop or cut down without success respondents expressed persistent desire to stop or cut down khat chewing the respondents cited wasting of time psychological dependence pressure from family or friends the catalyst nature of khat overall health impact psychosocial and economic harms as major reasons for the desire to stop one respondent said that not only the khat pushes you to stop but the associated drugs and activities also force you to stop khat khat is akatari catalyst hazardous use there were multiple reports of khat use in physically hazardous situations these are mostly during mirqana or harara the risks mostly occurred while driving a car working at a machine and electricity respondents relate the occurrence of risks to increased mental and physical tempo underestimating danger in other cases their mind would be preoccupied by thinking about chebsi there were respondents who prefer to persist in khat use despite frequent accidents specially driving a car a driver concluded that khat is a fuel for the driver as benzene is a fuel for the car the problem will be worse when alcohol is taken in addition effect on child women reported that they observe different behavioral changes in their baby when they breastfeed their child after chewing khat the baby sleeps poorly cries and screams and appears to have abdominal pain respondents also asserted that khat use resulted in decreased body weight of their child they added that even if the child was healthy initially it will be undernourished subsequently because chewing khat decreases the appetite of mothers which in turn decreases the breast milk production these women continue using khat while knowing and observing the the negative effect of their behaviorchewing khat on their baby quantitative results demographic characteristics and chewing behavior most of the participants were men single christians and amhara nearly half of the participants had started chewing khat before the age of 10 majority of the participants chewed khat on a daily basis with regular session of both at in the morning and afternoon from 300 pm 300 pm participants chewed different types of locally planted khats and quantification of the amount used depend on the type of khat the socio demographic and chewing characteristics of participants are summarized in tables 2 and3 problematic khat use indicators of problematic khat use were identified all were identified through qualitative exploration and were identical to the dsm5 criteria except one recurrent risky sexual engagement after chewing khat the commonest indicator of problematic khat use was persistent desire to use khat or unsuccessful effort at cutting down endorsed by 735 of the respondents continued khat use despite its harmful use and the use of other psychostimulants to avoid withdrawal symptoms were endorsed by 725 and 618 respectively other important indicators of problematic khat use were occupational and social impairment endorsed by over half of the respondents and craving all the indicators of problematic khat use corresponded to the dsm5 criteria of stimulant use disorder except risky sexual behavior which resulted either directly from the mirqana or as part of the deliberate effort by the khat user to reverse the negative after effects of the mirqana this behavior was endorsed by about a quarter of the respondent mirqanna physical cognitive emotional and behavioral manifestations of mirqana were described by the users the signssymptoms of mirqana shown in table 5 were all mentioned in the qualitative exploration except four which were extracted from the dsm5 criteria withdrawal experiences of problematic khat use problematic khat users reported different withdrawal signs and symptoms that occurred when users stopped their use or reduced the amount they used again most of these experiences were reported spontaneously during the qualitative exploration although the experiences match with the dsm5 list of symptoms for withdrawal in stimulant use disorder problematic khat use and reported health effect different physical health impacts of problematic khat use were reported many of the respondents have at least one physical health complaints the top five complaints were increased subjective temperature sleep disturbance gastric problem emotional distress and increased heart beat impacts of problematic khat use the psychological wellbeing social support drinking behavior facing threating experiences and overall satisfaction of khat users were examined the descriptive finding revealed that about half of the participants were problematic alcohol drinkers other majorities of the participants experienced serious social problem with friends neighbor or relatives divorce and financial difficulties they also had poorer overall life satisfaction scores although this seems to be worse among women mannwhitney u test was used to examine the difference in psychological distress social support harmful drinking and experience of threatening events between low and high risk problematic khat users low risk and high risk is operationalized as below and above the median those with higher level of problematic khat use pattern had significantly higher levels of psychological distress and harmful drinking pattern discussion this study was conducted primarily to determine what constituted problematic khat use despite the increasing interest in the harmful effects of khat and the interest to ban the use of khat in some high income countries like the uk 6 little is known about what constituted problematic khat use employing emic and etic approaches this study investigated what constituted problematic use primarily from the perspective of the users participants considered khat use both acceptable and problematic depending on the context and the pattern of use the acceptable uses included using for religious sociocultural and functional purposes denouncing khat use without understanding the context could be in itself problematic khat use was considered problematic if there was 1 impairment 2 loss of control in the use of khat and 3 withdrawal symptoms when not using khat specific indicators were shown in table 7 these are important indicators which are found in the dsm5 criteria stimulant use disorders the harm of drugs is mainly evaluated to its physical harms dependency and social harms and khat has been listed at the bottom line 28 the emic and etic approaches were overlapping defined pattern of problematic khat use can be identified this study focused on known individuals with established khat use behavior and high level of problematic pattern of use within the population problematic khat use may be minimal respondents were mildly moderately and severely problematic using dsm5 criteria for classification of risk level the study was analogous to other studies with etic approach only 29 30 31 with specific criterion of problematic use 735 of the participants had a practice of persistent desire or unsuccessful efforts to cut down or control khat chewing this had been repeatedly reported but many chewers fail to succeed the study also found out different withdrawal symptoms the most frequent reported were yawning irritability craving and depression recent studies reported that psychological dependency was endorsed by 51 participants in yemen 30 and 522 of khat chewers in saud arabia 9 as measured by severity of dependency scale another study among yemeni residents in uk also showed that 31 of khat chewers reported dependency as measured by american psychiatric association diagnostic statistic manual 29 in ethiopia from the general population problematic khat use was found out about 20 and 06 chew to avoid withdrawal symptoms 2432 other problems of khat were health harms about 814 of the participants had at least one health compliant other studies also confirmed that khat had mild moderate and severe kinds of health harm depending on the pattern of use 63334 but as far as the qualitative study revealed it is difficult to conclude as khat itself causes the above health harms sugar candy and other similar substances which are taken during chewing khat to decrease the bitter taste pesticides of the khat plant and the repeated use of tobacco and alcohol during and after khat use might also be associated with reported health harms recurrent risky sexual engagement after chewing khat which was confirmed by 245 of the respondents was also one indicator of problematic khat use non problematic khat users didnt engage to risky sexual engagement due to the feeling high of khat rather problematic khat users do this may be because of poor fig 2 reported health impacts of problematic khat use fig 3 overall satisfaction domains stratified by sex in judgment during feeling high the effect of sexual desire of khat chewing together with opposite sex in khat cafes and to reduce the feeling high other studies also found that khat chewing results in risky sexual engagement and is a risk behavior for the spread of hiv infection 3536 other dimensions of khat harm were the functionality and economic impacts fifty five point 9 and 578 of the participants reported that khat chewing behavior affects their social and occupational functioning negatively other studies also reported this 1920 the deterioration of such functioning and a decreased ability to attend social gatherings andor festivals were commonly reported the average amount of money spent on khat is much higher than the amount of money used to define the poverty line adding this to the expenses incurred to support the use of other substances like cigarettes alcohol shesha pea nut sugar candy soft and hot drinks and rent for sitting at rooms for khat sessions to the cost of khat chewing could be much more substantial one major limitation of the current study was the issue of generalizability the sampling method employed here was nonprobability the study also employed qualitative and cross sectional quantitative research method which didnt show causal relationship among variables and the impacts of problematic khat use were only the perceived and experiences of the participants conclusion in conclusion the study demonstrates that problematic khat use can be defined and evaluated interestingly there was a major overlap between the emic and etic approaches although the list of indicators for problematic use was more extensive in the emic approach there were significant problems related to problematic khat use and problematic use of khat was prevalent among the study participants there were also significant distressing experiences related to the aftereffects of excess use and withdrawal thus it is better if there is an integrated prevention and treatment strategy for problematic khat use further large scale population based and controlled studies are also required table 7 main indicators of problematic khat use identified through the emic approach quantity of khat using large quantities of khat the use of increasing amounts of khat through time and the need to use other substances to either enhance the stimulating effects of the khat or to reverse the excessive stimulant effect of khat time of use use of khat in the morning taking too much time to use khatthroughout the day or night and using during unscheduled times and if the users life is dominated by khat use repeated excessive negative impact during or after using khat including negative behavioral effects withdrawal effects when reducing the amount used or cessation of use and problematic management of these withdrawal effects craving for khat desire to stop or cut down use but unable to do so social and occupational impairments resulting from khat use using khat even when it is hazardous major negative impact on finances physical harms resulting from khat use or from withdrawals abbreviations dsm diagnostic statistical power fast fast alcohol screening test fgd focus group discussion idi indepth interview lte list of threatening experiences na narcotic anonymous oss oslo social support spss statistical package for social science who world health organization authors contributions all the three authors were equally contributed to the study and had substantial input to prepare the manuscript all authors read and approved the final manuscript competing interests the authors declare that they have no competing interests

background khat is a psychostimulant herb which has been in use in traditional societies in east africa and the middle east over many centuries although khat is reported to cause various health problems what constitutes problematic khat use has never been systematically investigated this study explored the acceptable and problematic uses of khat from the perspective of usersthe study used a mixed methods design exploratory sequential in which qualitative emic data were collected to develop a framework to define problematic khat use the qualitative data were gathered through indepth interviews n 13 and focus group discussions n 34 by supplementing the emic experiences considered to constitute problematic khat use with an etic definition dsm5 criteria for stimulant related disorders a structured questionnaire was developed subsequently a crosssectional evaluation of 102 respondents was carried out respondents both for qualitative and quantitative study were selected through purposive sampling and snowballing methods qualitative data were transcribed and subjected to thematic analysis whereas quantitative data were analyzed using descriptive and nonparametric statistics results khat use was acceptable socioculturally and for functional purposes however even in these acceptable contexts there was a restriction to the amount frequency and type of khat used and in relation to the experience of the individual using khat and other personal characteristics more specifically khat use was considered problematic if there was 1 impairment in social and occupational functioning 2 loss of control in the use of khat and 3 withdrawal symptoms when not using khat among the participants who use khat n 102 451 n 46 used khat on a daily basis the commonest indicators of problematic khat use endorsed by the khat users were loss of control over chewing 735 continuing use of khat despite harm 725 and efforts to avoid withdrawal from khat 618 conclusion despite reported religious sociocultural and functional benefits to the use of khat those with defined problematic khat use have impaired mental health and social and occupational performance comparison of these respondent defined indicators of problem behavior matched almost completely to the dsm5 eticdefined understanding of problematic stimulant use although the findings have relevant clinical research and policy implications the study focused on users purposively identified future larger scale definitive studies are required to make concrete policy recommendations

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introduction the current health crisis has heightened the importance and value of healthy living in preventing and treating health conditions 1 there have been many approaches to promote healthy lifestyles 2 some have focused on cardiorespiratory and muscular fitness to prevent and treat cardiovascular disease 3 others conceptualize it as the integration of habits that prolong the healthspan of individuals 4 activities such as physical activity consuming nutritious and healthy food not smoking or consuming recreational drugs and maintaining an appropriate body weight are essential to this health the current health crisis has also pushed mental health as one of the priorities since lockdown considerably increased psychological disorders in teenagers and young adults 5 the change in habits amid the pandemic had direct repercussions on these key pillars of wellbeing habits are critical for healthy living behaviors these consist of automated responses that develop through repetition and are often performed without little or no forethought figure 1 depicts the four stages necessary for habit formation starting from a decision that is sustained through time until it becomes an automatic behavior 6 the strongness and automaticity of an established habit may pose difficulty in changing it because shortterm behavioral gains may be lost in the longterm context 7 this has to be taken into consideration when designing strategies for habit promotion or formation habits are forged closely in the familiar context but sociocultural norms and perceptions may shape them throughout time while habits in early childhood are influenced directly by parents selfcare gradually shifts towards selfdirection 8 elements related to the individual such as selfconsciousness in teenagers and young adults and interpersonal elements such as belonging to a group or peer pressure may impact the perception and formation of new habits habits related to health are no exception 9 raising challenges in latin america although all individuals are entitled to equal rights and opportunities including the right to a healthy life the integration of habits to prolong the health span seems to challenge underserved communities 10 latin america a culturally diverse region with a vast territorial extension has many challenges in promoting healthy habits the social context is characterized by deep inequities where factors such as ethnicity rural residence or low educational level translate to inadequate access to health services 11 the eradication of poverty and the reduction of inequality in all its dimensions was a pressing issue in the political agenda however the pandemic aggravated these conditions factors such as informal employment limited access to education crime urbanization patterns lack of economic growth and weak health or social protection system increase the vulnerability 12 socioeconomic status may be one of the main contributing factors to this phenomenon insecurity in neighborhoods discourages children and parents from staying outdoors in parks or streets 13 social deprivation from the community and inequality in access to health are very real problems the monthly mean income per family in latin america varies between 773 usd in panama which is one of the highest and can be as low as 175 usd reported in cuba 14 other countries such as brazil average 335 usd colombia 244 usd and mexico 518 usd 14 this forces families where two parents are present both have to work to provide which sometimes increases the frequency of the consumption of prepackaged or fast food the consumption of healthy foods may also be limited due to their higher cost according to the world health organization the regions pressing regional challenges are obesity depression and anxiety 15 a prominent factor of the complexities in the area is the alarming rate of undernutrition and the highest prevalence of childhood obesity 16 the latin american federation of obesity societies issued a consensus statement compiling data of a prevalences above 30 in obesity which is increasing at a faster rate than in the rest of the world 17 according to ng et al the highest prevalence of obesity is found in el salvador and paraguay for women with a prevalence of 33 and 30 respectively 18 and uruguay and chile for men with a prevalence of 233 and 22 respectively alarming statistics from argentina show that in children this problem impacts 99 of the population mexico holds the second place in the world with 40 of obesity in adults 18 diets that are high in fat and sugar but low in micronutrient and an increase in sedentary lifestyles are in part responsible for this phenomenon another level in which being overweight has its toll is on emotional and psychological dimensions 19 in the emotional domain depression is a major challenge it refers to persistent feelings of sadness and loss of interest affecting a persons behavior and often impacting daily activities and causing physical or other emotional problems 20 recent data shows an increasing mental health problem with a prevalence in teenagers and young adults around 10 in latin america 21 studies have found that its prevalence is as high as 47 in argentina and bolivia 58 in brazil 47 in colombia chile and uruguay are in 5 peru 48 and mexico and venezuela follow closely with 42 22 another increasing mental health issue is anxiety which refers to an unpleasant emotional state characterized by feelings of tension apprehension and worries and by activation or arousal of the autonomic nervous system 23 studies have found that its prevalence is around 63 in argentina 93 in brazil 65 in chile 58 in colombia 36 in mexico 76 in paraguay 57 in peru 57 and 44 in venezuela the pandemic has also taken a toll on mental health and wellbeing in the young population a rapid survey conveyed by the united nations international childrens emergency fund showed that in latin america 27 of the population between 13 and 19 have experienced symptoms of anxiety and 15 of depression 24 a change in emotional wellbeing may also promote other unhealthy activities such as alcohol tobacco and other recreational drug abuse which is a rising concern among the young population 25 according to the world health organization worldwide more than a quarter of all people aged 1519 years which represent 155 million adolescents are current alcohol drinkers alcohol and drug use in children and adolescents is associated with neurocognitive alterations that can lead to behavioral emotional social and academic problems in later life regarding tobacco use most studies trace its start to adolescence globally at least 1 in 10 adolescents uses tobacco although there are areas where this figure may be higher 26 there have been many legislations that criminalize itsproduction and distribution however drugs such as cannabis are still heavily used in latin america with prevalence rates between 4 and 13 27 it is also widely used in young people estimates from 2018 are that at least 47 of people aged 1516 years used it at least once during the year 26 overall the socioeconomic inequities as well as some aspects of the cultural and educational settings make the latin america region a very particular ecological niche with specific and rising challenges that will need to be addressed from different approaches strategies to promote healthy living in child and adolescents according to the healthy living for pandemic event protection network adhering to healthy living behaviors has a direct impact on a persons quality of life 8 this provides insight not only in physical dietary aspects sleep habits etc these key elements as well as the emotional sphere have yielded to a holistic view of health physical sphere many interventions focus on this sphere by understanding the obesitypromoting factors stakeholders can develop targeted interventions to mitigate the problem the major contributors to the increased rate of obesity and overweight may be understood in two levels food and physical activity the food environment changes regarding global national neighborhood or in the school environment regarding physical activity factors that impact negatively are the reduction of walking as a transportation mode the increase in access to motorized vehicles and the increase in sedentary leisure activities 28 habits that predispose to overweight and obesity rely on the establishment throughout development and growth which makes it difficult to overcome them with crosssectional interventions several programs have succesfully implement programs on prevention and reducing obesity prevalence in the region the plan of action for the prevention of child and adolescent obesity was signed in latin america to promote an active lifestyle encouraging the use of bike paths or physical activity programs at school 2930 this initiative pushed the implementation of fiscal policies on foods with a high energy content and low in nutrients in mexico it resulted in taxation of sweetened soft drinks and highcalorie food 31 in 2016 chile promoted labeling the front of the packages with a blackandwhite warning sign if it exceeds defined limits of calories saturated fat sugar and sodium 32 this measure was adopted by mexico in 2020 and is also being promoted by the colombian government to promote healthier food choices 33 in 2013 the mexican health ministry designed and implemented the campaign called chécate mídete muévete to inform people about food and nutrition through public awareness positive and motivating messages and information were transmitted on television or radio to raise awareness about the importance of prevention through commercial spots these messages also motivated people to attend preventive medical checkups as well as for receiving guidance in health promotion 34 however when the effectiveness of this campaign was analyzed the program was far from effectively decreasing the prevalence of overweight obesity and diabetes mellitus some of the limitations included poor outreach to rural communities and the transmission of an average of 13000 advertisements of junk food products and 42 different brands transmitted in parallel 35 these factors might explain why the program did not reach the originally planned impact and its cancelation afterward in 2011 brazil launched the academia da saúde program 36 as a healthcare promotion strategy that works with the implementation of public spaces known as hubs where physical activity practices are offered to the population these centers are part of the primary health care network and have specialized exercise equipment and qualified professionals to advise the users as a point of attention in the territory they complement comprehensive care and strengthen health promotion actions in conjunction with other health programs and actions such as the family health strategy the extended family health centers and health surveillance lifestyle sphere lifestyle habit changes and promotion may be the most difficult areas to address in latin america on one hand the family context does not foster healthy habits which could be related to the economic struggles of the population on the other hand insecurity and crime throughout the regions add another level of complexity interventions focused on these spheres may probably be the most effective in developing healthy lifestyle habits in the long term hence promoting a healthier status of our population mexico has second place in child obesity many interventions have been made to prevent childhood and adolescent obesity unfortunately there have been no results that indicate the effectiveness of these strategies one focuses on adding an 8 tax on food with an energy content exceeding 275 kcal per 100 grams and 005 usd per liter on sugarsweetened beverages 37 another strategy focuses on food labeling these labels indicate the foods caloric input the excess of saturated fats sugars and sodium to raise awareness and provide guidance to the consumer the mexican strategy involved banning radio or television advertisements during hours in which children may be a significant part of the audience although different approaches were implemented habits have not significantly modified the prevalence of overweight and obesity mexico still has one of the highest rates of child obesity worldwide 37 in order to mitigate it a threemonthlong educational intervention was designed called healthy recess aimed to promote healthy eating and physical activity in children this strategy also allowed the identification of the perceptions of the target population and the implementation of healthpromoting interventions among the activities was a traffic light system where students had to associate cards with images of food or physical activities green yellow and red colors allowed students to classify food or activities according to their healthiness regardless results showstudents choose their food based on flavor regardless of their caloric intake or nutritional value this may be due to the lack of parental guidance and school environments not offering enough healthy alternatives or the lack of healthy alternative in lunch boxes 38 san pedro de pinta is a program created in 2011 in san pedro municipality in mexico with the purpose of recovering the public space to promote sustainable mobility social and family interaction and overall a healthier lifestyle 39 this program takes place every sunday starting at 700 am until 100 pm families can walk with their pets and ride bikes in this avenue where vehicular circulation remains closed and becomes 5 kmlongpark the initiative has been well received with approximately 12000 people attending every sunday it teaches new generations a different city model but more importantly it has also created spaces that enable the establishment of healthy habits that lead to a healthier lifestyle in the long term unorthodox interventions have explored technology as the basis for reaching young adults 40 this aspect could be beneficial because of the increasing number of internet users in the young sector of latin america the exergames in brazil implemented a strategy with two groups one of them promoted physical activitypromoting interventions plus virtual games that promote healthy habits and the second group did solely physical interventions no difference between the two groups 41 emotional sphere perceptions of health habits tend to be associated with the nutritional state or bmi parameters but the multidimensional concept of health is often overlooked particularly in adolescents the focus has been mainly on physical appearance and average weight but participation in school activities to exercise a sense of belonging with friends and the school community is important as well 42 the current health crisis has brought significant changes in this sphere as well social distancing and the lack of socialization in school contributed to this a study by genta et al evaluated the sleep habits and quality of brazilian adolescents and concluded the pandemic negatively affected their sleep quality 43 a webbased survey conducted during the first peak of the pandemic in brazilshowed the negative impact on mental health with a high prevalence of psychiatric symptoms in young adults in brazil this study also showed that the young population was more susceptible to depression anxiety and stress during the health crisis 44 with almost all our efforts focused on mitigating contagions and infection emotional wellness has been overlooked but a direct impact in the emotional sphere of wellness has been demonstrated among the consequences an increase in depression anxiety and insomnia in heavily affected countries like china and italy frontline health workers are also at risk of developing posttraumatic stress disorder as a consequence of the coronavirus outbreak 45 schools have dealt with closure mainly focusing their efforts in continuing the curricular delivery but children and young adults have also been victims of the psychological consequences of the pandemic some institutions have implemented programs to mitigate the consequences of social distancing in their students therefore the objective of this study was to assess the perception that adolescents and young adults in latinamerica have of the importance of healthy living behaviors in the physical emotional and lifestyle spheres methodology the approach considered for this study was quantitative and descriptive with a crosssectional design this process allows us to identify relevant variables and data to understand a complex phenomenon the sampling strategy was a convenience sample that consisted of 192 young adults in three countries of latin america brasil colombia and mexico as an instrument an eight closedended question survey was designed following the hlpivot framework of healthy living an additional openended question was included to represent the psychological wellbeing of the students which has become a priority amid the pandemic the first question considered that participants ordered according to their perception of importance the eight elements of the spheres in the healthy living behaviors model physical activity nutritional state access to healthy food body habitus sleep habits avoidance of noxious habits emotional wellness and spiritual wellness the rest of the questions focus on participants selfassessment in each of these behaviors these items consider a 1100 scale for participants to intuitively assess their current state to analyze the trends in the items and the different spheres descriptive statistics were considered the survey also included an openended question that asked participants to describe how their perception of wellness evolved as a result of the pandemic this question added some depth to understanding the perception of the students and context as part of the analysis we considered a content analysis identifying themes categories and codes to describe similarities and differences in the participants perceptions as part of the ethical considerations of the study it is important to highlight that the participants were informed about the purpose and granted written informed consent the study followed all the applicable regulations and recommendations of the comité de ética en investigación de la escuela de medicina del instituto tecnológico y de estudios superiores de monterrey ethical committee that grants approval of the research protocols the study was conducted following the declaration of helsinki results participants ages ranged from 15 to 25 years old however 67 of them were in the 1821 years range regarding healthy living behaviors in general participants prioritized the eight elements of the spheres in the healthy living behaviors model the elements that participants prioritized higher were emotional wellness nutritional state and physical activity these results are presented in table 1 if the data is contrasted by country 60 of brazilian participants identified physical activity as the first choice which was prioritized as the first choice only by 886 of colombians and 825 of mexican participants the results of colombian and mexican participants prioritized emotional wellness as the first choice with 3625 and 4021 respectively according to the results participants selfassess higher on their nutritional status with a weighted mean of 7794 the lowest selfassessment was found on avoidance of noxious habits with a mean of 2909 these results are presented in table 2 the results of the openended question included in the survey were interesting as well participants reflected on how their perception or priorities in healthy behaviors had changed due to the pandemic five categories emerged from thematic analysis 1 awareness of needing emotional wellness 2 transitioning to a selfcare approach 3 increase in the importance of physical activity 4 gaining a holistic health and wellness perspective and 5 perception that their wellbeing has being worsening during the pandemic the highest number of participants 289 stated that their awareness of needing emotional wellness increased amid the pandemic some extracts of their reflections are the following my priorities changed and i focused more on my mental health i value my psychological wellness because it is important for remaining focused in school emotional wellness has an impact on all aspects of your life when you are not mentally healthy you cant perform in your life as usual according to participants communities are now prioritizing selfcare higher i make myself a priority in my life i consider this important to achieve my goals in life i prioritize the things that make me feel happy and make me feel good close to 1491 of them stated that it was the current health crisis which brought the opportunity to focus on the importance of this element i now have metime and value my selfcare i have spent a lot of time with myself and have learned the importance of taking care of myself the importance of physical activity increased as participants spent more time in their homes close to 1442 the majority emerging from participants in brazil commented on this theme i have made my physical wellness a priority in my life being sedentary kills… you have to exercise yourself i have made physical activity and healthy eating a priority in my daily routine several participants took into consideration more than one of the spheres of healthy behaviors addressing the importance of gaining holistic health wellness for example some overspossed the physical and mental spheres the pandemic made me prioritize controlling my emotions stress anxiety and opened my eyes to the importance of having daily physical activity socializing and having recreational activities to be emotionally well i knew before the pandemic but now i have seen a stronger correlation between every aspect of my health you cant have good mental health without physical activity a healthy diet or relaxing activities i also learned to prioritize activities that make me feel good and step aside from the things that emotionally drain me others described the importance of balancing them and revisiting to analyze the needs in that specific moment of time i give more importance to socializing my mental health and psychological wellness it came to my attention that wellness components are not static they change every day and the needs of each one also change on a daily basis one component does not compensate for another on the other hand several students reported a perception of their wellbeing had being worsening during the pandemic my personal wellness has worsened amidst the pandemic it is tough to be ok in a wellness state since the pandemic started some describe the causes that have impacted for example the motivation i dont feel motivated to exercise the pandemic has affected me physically and psychologically discussion in this study mental health was the highestranked item in participants priorities followed by an excellent nutritional state and physical activity concerns and assumptions of the psychological consequences of this pandemic have been highlighted in editorials in different countries now an emergence of the first reports of the toll that quarantines and social distancing measures had are being published these range from anxiety stress an increase in substance abuse and can be as severe as depression some others report an increase in suicidal idiation and suicide 46 undoubtedly the current health crisis has affected the change of this perception which was also supported by the high frequency of answers related to emotional health in the themes of the comments received physical activity has been one of the most traditional concepts associated with healthy living but it is interesting to observe that emotional wellbeing was higher in the scale of importance the results on the thematic analysis reflect the awareness of the importance of this sphere however the challenges in the region such as the increase of crime and the unsafety in open public spaces might have impacted the opportunity of participants to practice exercise 13 there is also the fact that quarantine led to social distancing and the consequent decrease of spaces available for exercising participants selfassessed low in some of the hlb for example in the consumption of drugs and the integration of noxious substances as part of their habits the study depicted a consequence of the pandemic substance abuse poses another interesting and raising challenge among youngsters worldwide the complex economical and social context of latin america and the increasing rate of substance abuse bring into focus the need for assessing and educating the population with increasing rates of alcohol consumption 27 and an increase in the stressors amid lockdown and the pandemic it remains to be seen if this has an impact on this parameter when pandemic is over probably interventions in the near future will be needed regarding these behaviors a surprisingly high assessment of the participants in their nutritional state might be the result of the taxation policies that the different countries have implemented this is quite important as energydense and nutrientpoor diets are factors that studies have linked with overweight and obesity still the promotion of healthy food has still to overcome the economic and financial challenges of the latin american context the social interaction restrictions and quarantine measures resulted in indoor physical activities during the pandemic in young people even of those who were active before isolation diminished considerably the results of this study are similar to the results of brito et al 47 as the authors demonstrated that the majority of adolescents were unable to maintain daily physical activities despite claiming to be motivated some of the root causes might be lack of physical space or a safe setting to exercise there was a clear shift in the participants perception regarding the importance of some aspects of wellbeing amid the pandemic the awareness of participants of the need to prioritize aspects of health such as emotional wellness these shifts may be due to quarantine but also influenced by all the interventions that promote a healthy lifestyle that have been implemented throughout the last years physical aspects which have been reported as priority had the second importance for our participants as an encouraging first step lifelonglearning habits depend on selfdirected commitment 42 the socioeconomic background in latin america may contribute to a sedentary lifestyle and the growing rates of obesity still the habit developmental process needs to be promoted and the economic or social limits are yet to be addressed interestingly a more holistic conception of health arose among our participants many of them stressed the importance of health being composed of more than one aspect of hlb such as emotional wellness socialization physical activity and nutrition new strategies should focus on providing wellness programs with these intersections school space might be an ideal environment to foster healthy habits that can permeate the family and the community especially in younger individuals 6 strategies become more effective when they include awareness that comes from the parents so that they serve as models of healthy lifestyles such strategies should include in the design the specific needs of the context and target population but also the promotion of the habits in the long term and the familiar context traditional healthcare has relied on the reductionist approach nevertheless there has been a shift in this tendency and now healthcare revolves around numerous extrinsic or intrinsic aspects that influence the network of health also known as an holistic approach 2 this was clearly perceived by some of the participants that established a correlation between each aspect of the hlb and acknowledged the interdependence between them in the reflections on the comment section perhaps this might be due to all the interventions of hlb promotion this population has been immersed in throughout their formative years main limitations of our study may reside in the crosssectional approach that we used the students perception was assessed during one specific period of time and this might not be a reflection or their overall wellness a longitudinal approach might be needed to better understand it also this study took place during the pandemic which per se could constitute a bias in the awareness on the importance of mental health perhaps during a less stressful time the students perception of the priority of mental wellness aspect could change or be scored lower in the importance scale this is not a qualitative study but offers a glimpse into the students point of view conclusion even though geographically different the latin american context shares a common pattern the adoption of healthier behaviors face innumerable barriers including the lack of social support cost of adopting healthy behaviors difficulty in daily routines especially in time management cultural preferences and environmental restrictions with social distancing amid the pandemic a major shift in the perception of holistic wellness has emerged taking into focus the emotional sphere of a persons life and promoting the inclusion of different aspects of the healthy living behaviors to have an integrated perspective of health and its components many factors may hinder the implementation and promotion of the hlb these need to be addressed from different approaches first considering the background and the ecological niche in which the population resides it may be the main obstacle that needs to be overcomed second taking into focus the problem around which strategies will be implemented third taking into account the importance of promoting health as a whole and lastly the longterm requirement to habit forging otherwise they will not be effective collaborations ar garcia m lopez and a mendez contributed to the design and implementation of the research mm diazlopez ar garcia a mendez and db dibai contributed to the colection of the data ar garcia and a mendez analyzed the data mm diazlopez ar garcia a mendez m lopez and db dibai did the writting of the manuscript m lopez and a mendez proofread and edited the final version of the manuscript all authors provided critical feedback and helped shape the research

resumo o completo bemestar físico mental e social se refere a um novo conceito de saúde muito além da ausência de doenças se os indivíduos são confrontados com profundas desigualdades sociais em que fatores como etnia moradia em zona rural ou baixo nível educacional se traduzem em um acesso menos adequado aos serviços de saúde podendo ser um desafio adicional para aderir a comportamentos de vida saudável o objetivo deste estudo foi avaliar a percepção de adolescentes e adultos jovens na américa latina sobre a importância dos comportamentos de vida saudável cvs nas esferas física emocional e de estilo de vida a abordagem é considerada quantitativa e descritiva com desenho transversal a estratégia de amostragem foi por conveniência a amostra foi composta por 192 adultos jovens em três países da américa latina brasil colômbia e méxico os resultados mostram que os participantes priorizam um maior bemestar emocional eles afirmam que a crise de saúde mudou a percepção pois agora valorizam mais a saúde emocional e compreendem a importância da combinação dos diferentes aspectos do bemestar o contexto latinoamericano desafia o desenho de estratégias com uma perspectiva holística da saúde com complexidades nos domínios econômico e sociocultural palavraschave comportamento saudável

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d ementia is one of the most feared medical conditions worldwide it represents a significant global challenge to health and social care 12 recent evidence suggests that dementia rates have decreased in the last few decades in the united kingdom and other parts of western europe 3 4 5 similarly in the united states the framingham heart study has shown that agespecific incidence rates of dementia have decreased by almost 20 within the last few decades and the greatest declines were apparent in individuals with higher educational attainment relative to more basic educational attainment 6 education may serve different roles in the development of dementia it is a proxy for earlylife experiences and socioeconomic status it is related to future employment prospects income and wealth it determines occupational exposures and characteristics of adult life and it provides lifelong skills for optimal mental abilities and mastery education is also thought to be a marker of cognitive reserve which appears to be protective against cognitive impairment and dementia risk offering an increased neural network and compensatory mechanisms throughout the life course even when individuals are facing neuronal death 7 recent systematic reviews have highlighted that low educational level was associated with a higher risk of dementia incidence 8 as well as with greater risk of dementiarelated death 9 some of this evidence highlights that the role of education varies according to period and sociocultural context the variation in countryspecific regulations on compulsory schooling and variations in measurement could account for the differences reported in the literature moreover given that education is typically completed many decades before dementia onset other individual and areabased components of ses such as wealth income and area deprivation may provide a more accurate indication of current socioeconomic resources also at older ages accumulated wealth represents a more robust measure of socioeconomic resources than income or occupation alone 1011 there are relatively few studies to date that have used socioeconomic indicators other than education to investigate dementia risk a recent analysis of the health and retirement study compared various ses markers including parental education and education and income associated with latelife memory performance and decline these findings indicated that income was most strongly associated with decline although education was the most influential determinant of baseline memory 12 another aspect of socioeconomic position involves neighborhood characteristics and the area of deprivation level which combines information from multiple domains such as income employment education skills training health disability crime and barriers to housing into a single measure previous results from the english longitudinal study of ageing showed that the index of multiple deprivation the official measure of deprivation in england was associated with cognitive performance in older age independently of education and ses these findings indicated that older women had lower cognitive scores if they lived in an area classified in the bottom 20 of imd when compared with those in the top quintile 13 in contrast meyer et al 14 showed that neighborhood ses had limited effects on executive function independent of personal characteristics such as education and ethnicity they also showed that individuals with dementia living in neighborhoods with higher ses experienced faster rates of decline before further statistical adjustment for education and ethnicity 14 these findings are consistent w ith the cognitive reser ve hypothesis which acknowledges a rapid cognitive deterioration for people with higher education once the pathological process associated with dementia has been initiated 7 however findings from the seoul dementia management project 15 showed there were no additive or synergistic effects between individuallevel and districtlevel of ses highlighting that the individual level contributed more to the development of cognitive impairment than the districtlevel ses we aimed to describe dementia incidence in a nationally representative cohort of british older adults and to investigate the association with different socioeconomic markers both via the individual characteristics and grouplevel characteristics a second objective was to examine the role of socioeconomic markers between 2 independent age cohorts methods data the english longitudinal study of ageing is a large multidisciplinary study representative of the english population both in terms of socioeconomic profile and geographic region 16 there have been 7 waves of data collection over a followup period of up to 12 years providing detailed information on health wellbeing and socioeconomic circumstances we used all the available data spanning 12 years across wave 1 to wave 7 refreshment samples were recruited at waves 3 4 6 and 7 for the current analyses we included only participants aged 65 years and older who were free of dementia at their baseline assessment at either wave 1 or through the refreshment sample of wave 4 ethical approval for each one of the elsa waves was granted by the national research ethics service all participants provided informed consent study variables dementia ascertainment dementia occurrence was determined at each wave using an algorithm based on a combination of selfreported or informantreported physician diagnosis of dementia or alzheimer disease or a score above the threshold of 338 on the 16question informant questionnaire on cognitive decline in the elderly 17 this questionnaire is administered to an informant who can evaluate the changes in the everyday cognitive function each item is scored from 1 to 5 the validity of this scale was previously examined 18 and the threshold used has both high specificity and sensitivity 19 socioeconomic indicators we measured ses at baseline including individual characteristics and areabased characteristics educational attainment was classified into 4 categories having a university degree or higher having completed alevels or the equivalent which is comparable with high school graduation having completed education below the alevel and lacking formal qualifications wealth was calculated by summing wealth from property possessions housing investments savings artwork and jewelry and net of debt 16 this was divided into quintiles the index of multiple deprivation is a composite measure which combines multiple arealevel ses indicators into a single deprivation score 20 we used the 2004 imd for england the highest levels of wealth education and imd were used as the reference group covariates based on previous findings 21 we considered baseline age sex marital status and baseline health being male married and having no health conditions were used as the reference groups age cohorts to investigate the change in incidence rates over the last decade we derived 2 groups age cohort i and age cohort ii this derivation was generated using a median split of all birth years statistical analyses incidence rates of dementia were computed by age and sex per 1000 personyears we performed χ 2 tests to ascertain if there were significant differences between ses groups to summarize the relationship between ses characteristics and dementia incidence cox proportional hazards models with age as the underlying time variable were used to calculate hazard ratios and accompanying 95 cis 22 we present the results from 4 models model 1 included unadjusted hrs model 2 included sex and marital status model 3 included model 2 with further adjustment for baseline health indicators and model 4 included model 3 and further adjusted for the additional socioeconomic indicators we used a forward stepwise approach and the akaike information criterion to select the model of best fit given that the original imd quintile classification was slightly underpowered we conducted a sensitivity analysis with the imd regrouped into a binary variable the survival time was calculated using participants baseline age at study entry until the age they were found to be experiencing dementia the point of their death or the end of the study period the schoenfeld residual test was used to test the proportional hazards assumption of the models 23 for individuals who did not report an exact diagnosis date or for those whose dementia was ascertained with informant questionnaire on cognitive decline in the elderly we considered the midpoint between the wave where dementia was first ascertained and the previous wave where it was not mortality data were used for participants who had provided written consent for linkage to official records from the national health service central register the records available the time of these analyses continued until february 2013 all analyses were weighted using the baseline crosssectional weights derived in elsa to ensure the sample is representative of the english population 24 given that death is often considered a competing risk for dementia incidence we conducted supplementary analyses using a modification of the fine and gray subdistribution hazards model 25 to account for the competing risk of death as described elsewhere 26 all analyses were conducted in stata se version 14 statistical significance was considered to be at or below the 05 level additional details are noted in the eappendix in the supplement results the sample included in these analyses was composed of 6220 individuals accounting for 43 218 personyears of these 463 were classified with dementia during the surveillance period and 1971 died the baseline median age was 732 years while the median age at the time of dementia ascertainment was 827 the sample included 6220 people of whom 3410 were female and 2810 male 3682 married and 3288 without formal educational qualifications only 1049 of 6220 participants attended university more men were educated to university degree level than women while more women had no formal educational qualifications the baseline median wealth for the overall sample was £15 100 for the lowest quintile the median wealth as £120 increasing to £180 000 in the highest quintile except for stroke which showed no clear ses gradient all other health conditions were inversely associated with each one of the ses markers ageadjusted and sexadjusted incidence rates for the full elsa sample and each specific age cohort are presented in table 1 and figure 2 the overall incidence rate was 1132 per 1000 personyears as anticipated there was a significant increase in dementia irs with age from an incidence of 438 in people aged 65 to 69 years to 24 1 there were no significant sex differences in the irs of dementia individual and areabased socioeconomic markers the multivariable analyses are summarized in table 2 education was not significantly associated with dementia incidence but wealth was a strong indicator per model 4 the hazards of developing dementia were higher for those in the lowest 2 quintiles of wealth compared with those in the highest quintile independently of covariates education and arealevel socioeconomic characteristics areabased characteristics measured with imd were also associated with dementia incidence in contrast with individuals in the leastdeprived areas the remaining 4 quintiles showed an increase in the hazard risk of developing dementia in model 1 however only the association with the secondhighest quintile maintained statistical significance in the fully adjusted model independent of the other individual markers of ses results from the first sensitivity analysis showed that those in the lowest 4 quintiles of imd combined had increased risks of developing dementia compared with those living in the least deprived area individual and areabased socioeconomic markers within age cohorts an investigation of age cohort showed that education was significantly associated with dementia for participants born between 1926 and 1943 but not for those born earlier in the century in age cohort ii there was a greater hazard risk of dementia for those with no education than those educated at university levels however this association was no longer significant once health conditions had been entered per model 3 wealth also seemed to have a stronger association with dementia incidence within age cohort ii although this was not statistically significant the association of imd with subsequent dementia was comparable in age cohort ii and the full sample while differences between imd quintiles were not present for age cohort i in models 1 2 and 3 before adjusting for other ses markers our additional analyses considering the competing risk of death showed a similar pattern of decline in dementia incidence over time and a stronger association between dementia incidence and all the ses markers including education but with no agecohort effects discussion in a representative sample of the english population aged 65 years and older we found a positive association between lower wealth and dementia incidence that was independent of education arealevel deprivation and covariates this suggests a higher risk for individuals with fewer financial resources the association was more consistent for participants born after 1926 compared with those born earlier in the 20th century additionally there was evidence for reduced incidence among participants born more recently however the 2 age cohorts overlap only for the group aged 75 to 79 years differences between age cohorts in the incidence of earlyonset vs lateronset dementias may also be present there are several possible explanations for the strong association of wealth with subsequent health outcomes wealth is an indicator of socioeconomic resources and it could represent a gateway to more mentally stimulating environments independent of the level of educational attainment previous elsa findings have shown that increased wealth facilitates greater digital literacy which is in turn associated with a reduced risk of dementia 27 furthermore increased financial status could provide broader access to cultural resources and behaviors or increased social networks which could ultimately contribute to higher cognitive reserve 728 the integrated psychosocial resource model proposed by matthews and gallo 29 argues for the accumulation of psychosocial and physical protective factors however in our analyses the relationship between wealth and dementia remained statistically significant even after controlling for healthrelated conditions associated with dementia there is also evidence that persistent ses disadvantage is associated with impaired physiological functioning 30 increased risk of depression 31 vascular disease and stroke 32 other factors such as reduced exercise poor diet 33 and inflammatory vascular risk factors 34 may also play a part in the association between low ses and increased dementia risk our data showed a differential ses distribution for the health conditions modeled as covariates in these analyses except for stroke which showed no clear ses gradient further work on the elsa data could explore these mechanisms in more detail to be able to disentangle the mediating role of psychological cardiovascular and metabolic functions on the association between ses markers and dementia the lack of a contextual areabased ses effect on dementia incidence is also notable previous elsa findings have documented a link between neighborhood deprivation and cognitive functioning independent of individual markers of ses showing that individuals living in the most deprived area of england had significantly lower cognitive scores compared with those living in the most affluent regions 13 our study found an inconsistent association between the area deprivation and dementia incidence with higher rates for individuals in the second quintile of imd compared with the top quintile the reasons for this are not clear associations were observed for the lower imd quintiles in first stages of covariates adjustment but these were no longer significant when individuallevel ses indicators were considered this suggests that much of the effect of area deprivation is explained by the individual characteristics of the people living in those areas rather than the features of the areas themselves in this cohort education was not a robust predictor of dementia incidence given that this association was no longer significant after age and sex were taken into account it is possible that this might be a specific cohort effect in the english population born and educated in the period surrounding the world war ii support for this speculation comes from an extensive population cohort collaboration which showed no apparent protective effect of education on the clinical presentation of dementia 35 their findings showed that individuals with higher education had heavier brains suggesting greater cognitive reserve but they were not necessarily able to compensate for the accumulation of vascular and neurodegenerative pathologies however the role of education might be sensitive to sociocultural context similar to our findings other investigations from the rotterdam study 36 the rochester epidemiology project 37 and the baltimore longitudinal study of aging 38 reported a lack of association between dementia incidence and education in contrast findings from the health and retirement study 39 indicated that higher education was associated with a lower risk of dementia prevalence between 2000 and 2012 and in the kungsholmen study 40 education remained significantly associated with dementia following adjustment for occupational class moreover in the canadian study of health and aging 41 fewer years of education were associated with an increased risk of lateonset alzheimer disease incidence while subsequent results from a 10year followup within the same study showed that high complexity of work with people or things was associated with a reduced risk of most dementia types 42 these findings indicate a protective effect of the occupational demands on the brain achieved through a lifetime occupational exposure it is therefore possible that individuals born before the world war ii may not necessarily have been able to access higher education but may have gained access to intellectually challenging jobs and growth opportunities after the war strengths to our knowledge this is the first longitudinal study to examine multiple facets of ses characteristics at individual and group levels simultaneously in association with dementia incidence within an agecohort context through the extensive monitoring of biennial interviews and a longterm followup we were able to use an integrative approach to study the association between various socioeconomic factors and dementia incidence furthermore we in the index of multiple deprivation q1 indicates least deprived q2 the second least deprived q3 the third least deprived q4 the fourth least deprived and q5 most deprived benefited from a more detailed assessment of wealth than what is available in most studies to date because this measure was computed on the basis of accurate information on multiple individual components rather than broad categorization of assets limitations this study also has limitations given that the ascertainment of dementia diagnosis is still challenging in the uk health services and elsewhere it is likely that the presented dementia irs are underestimated other common issues such as nonresponse and subsequent attrition are familiar to most longitudinal surveys 43 moreover because of a relatively small sample of dementia cases we did not explore the irs of dementia by specific typology although elsa is a demographically representative cohort the raceethnicity is 97 white 16 and we were therefore unable to investigate the effects that race ethnicity might have on the outcome of dementia furthermore we did not investigate the difference in dementia incidence by geographical regions given the high collinearity with imd lastly as in any observational study we cannot exclude the risk of confounding by other factors avenues for future exploration include examining the mediating role of cardiovascular disease lifestyle factors medical care and other risk factors that could influence the association between ses and dementia conclusions in a nationally representative sample of english people 65 years and older the hazard risk of dementia incidence was associated with socioeconomic indicators notably wealth socioeconomic inequalities were more marked in individuals born in later years than in those born earlier public health strategies for dementia prevention should target socioeconomic gaps to reduce health disparities and protect those who are particularly disadvantaged in addition to addressing vascular risk factors such as hypertension diabetes mellitus smoking and heart disease conflict of interest role of the fundersponsor the funders had no role in the design and conduct of the study collection management analysis and interpretation of the data preparation review or approval of the manuscript and decision to submit the manuscript for publication additional information the english longitudinal study of ageing was developed by a team of researchers based at university college london the institute for fiscal studies and the national centre for social research the data are linked to the uk data archive and freely available through the uk data services and can be accessed at discoverukdataserviceacuk

importance lower educational attainment is associated with a higher risk of dementia however less clear is the extent to which other socioeconomic markers contribute to dementia risk objective to examine the relationship of education wealth and areabased deprivation with the incidence of dementia over the last decade in england and investigate differences between people born in different periods design setting and participants data from the english longitudinal study of ageing a prospective cohort study that is representative of the english population were used to investigate the associations between markers of socioeconomic status wealth quintiles and the index of multiple deprivation and dementia incidence to investigate outcomes associated with age cohorts 2 independent groups were derived using a median split born between 19021925 and 19261943 dementia as determined by physician diagnosis and the informant questionnaire on cognitive decline in the elderly results a total of 6220 individuals aged 65 years and older enrolled in the study median interquartile range age at baseline 732 681783 years 3410 548 female of these 463 individuals 74 had new cases of dementia ascertained in the 12 years between 20022003 and 20142015 in the cohort born between 1926 and 1943 the hazard of developing dementia was 168 times higher hazard ratio hr 168 95 ci 105286 for those in the lowest wealth quintile compared with those in the highest quintile independent of education index of multiple deprivation and health indicators higher hazards were also observed for those in the secondhighest quintile of index of multiple deprivation hr 162 95 ci 106246 compared with those in the lowest least deprived quintilein an english nationally representative sample the incidence of dementia appeared to be socioeconomically patterned primarily by the level of wealth this association was somewhat stronger for participants born in later years

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background in the netherlands less educated inhabitants liveon averagesix years less than most educated people and the difference in healthy life expectancy between these groups is almost 19 years 1 although the healthy life expectancy of less educated people has increased considerably in the last decade the difference in life expectancy between the two groups has remained the same 1 health inequities are a complex problem caused by the interplay between individuals groups communities and multiple factors in the social physical and economic environment 2 3 4 5 to date health promotion programs have not been successful in substantially reducing the health gap between the higher and the lower socioeconomic groups it is therefore a challenge to develop more effective strategies 6 7 8 9 10 these strategies should be based on an ecological perspective addressing factors at multiple levels and looking at the interaction between factors 11 12 13 such strategies are being developed in the community health promotion program called voorstad on the move in line with national and local policy objectives the aim of the program is to contribute to the improvement of health and to find ways to reduce health inequities 1415 the program is being implemented in four socioeconomically deprived neighborhoods in a city district of 10750 inhabitants in a city in the east of the netherlands between july 2016 and january 2020 in voorstad both the socioeconomic status and the health status of inhabitants are relatively low compared with other parts of city 16 casus community health promotion program voorstad on the move vom is grounded in a socialecological perspective based on the exploration of the health situation in voorstad concurrent with views on health promotion and insights from the literature 17 18 19 20 21 vom puts three action principles at its center citizen participation intersectoral collaboration and a health supportive environment that that were emanated from the results of an preparatory study 22 the aim of the preparatory study was to get an impression of the health situation in voorstad in order to decide on the program goals and methods this preparatory study consisted of seven focus groups with citizens and 30 interviews with professionals from different disciplines about health and health behaviors overall the top three most mentioned aspects of health were feeling at ease being in control and being together with friends family and neighbors there was a clear focus on health as an asset or resource for meaningful living 2324 the inhabitants barely mentioned unhealthy lifestyles eg obesity and smoking which are the focus of professionals and of the data in monitor and health surveys these qualitative data were supplemented with quantitative data from health monitors 25 and the local citizens survey 26 the discrepancy in perceptions on health and wellbeing between inhabitants and professionals emphasizes the need to include citizens perceptions in health promotion activities 192027 the voorstad inhabitants viewpoints are the starting point for vom thereby giving the inhabitants ownership to address health in a positive way focusing on assets and resources 24 this means that activities in the program are not chosen or planned beforehand but rather developed and implemented as a result of questions and needs expressed by voorstad inhabitants citizens active involvement and responsibility for activities strengthen their health literacy and empowerment 28 29 30 citizen participation including defining health developing implementing and evaluating activities with and by the citizens 3132 is one of the action principles in vom another important finding of the preparatory study was the presence of a comprehensive infrastructure of public welfare social support sports and care organizations community centers and networks and alliances in which both professionals and inhabitants collaborate 22 intersectoral collaboration 33 34 35 36 between primary care social services and environmental policy and public health workers is therefore a second action principle of the program vom joins and uses the existing social infrastructure to add the broader view on health and bring in knowledge to make health promotion activities possible both inhabitants and professionals mentioned barriers that hinder healthy living and keep them from changing behavior such as accessibility of sports facilities and prices of healthy foods as well as social norms attitudes and habits this indicates the third action principle of vom creating a supportive social and physical environment for health 37 38 39 these action principles can be defined as actions processes or mechanisms that help establish the effect or impacts of a health promotion program 40 41 42 the premise of principles for action is that they contribute to health through multiple pathways and serve multiple purposes such as program effectiveness the creation of supportive environments for health and empowerment of all stakeholders both professionals and citizens 3243 in july 2016 two health brokers started to support these action principles by facilitating citizens participation in developing and implementing activities that fit citizens needs and build healthy alliances recent studies show that the broker role is essential in facilitating intersectoral collaboration and exchanging knowledge between stakeholders 44 45 46 the aim of the vom program is to improve the perceived health of the voorstad inhabitants mostly low ses families and achieve changes in the social and physical environment that support health and healthy behavior the overall research aim is to study the impacts and action principles of vom comprehensively on different levels this will contribute to finding ways to reduce existing health inequities therefore four interrelated research questions have been formulated theoretical framework because the vom program is based on a socialecological perspective on health the theoretical framework consists of different theories and models that recognize the link between practice and context within social situations to study and understand impact on health and the environment on the one hand and the working of the action principles on the other hand a framework to facilitate and evaluate a community health promotion program will be used 324748 this framework fig 1 visualizes the relation between the social environment health predicting mediators and population health status it provides operationalizable variables that moderate the relation between the social environment and health predicting mediators the moderating variables are the action principles in the vom program citizen participation intersectoral collaboration and a health supportive environment are used as entry points to make the social environment of health researchable and manageable by communities social practice theory 49 the reasonable person model 50 and the healthy alliances framework 33 are used to understand the working of the action principles comprehensively and on different levels spt integrates the individual with his or her social environment and will be used to study the mechanisms of citizen participation and health behaviors in contemporary theories of social practice health and wellbeing are considered to be outcomes of participation in a set of social practices commonly created by the reality of everyday life 49 following shove et al 51 a practice is defined as being constituted by meanings about how fig 1 framework to facilitate and evaluate community health promotion 48 and why to do things materials and competences both tacit and explicit fig 2 in this study participation and health behaviors will be regarded as social practices rather than only individual behavior because they fit with the community approach focusing on social change instead of attempting to change what shove et al 51 refer to as individuals abc the rpm is a conceptual framework that links environmental factors with human behavior 50 people are more reasonable cooperative helpful and satisfied when the environment supports their basic informational needs the same environmental supports are important factors in enhancing human health reasonableness is used rather than wellbeing because it focuses on bringing out the best in people central in the rpm is the management of information either visual or written indicating that people are more reasonable when their informational needs are met 52 the rpm consists of three domains building mental models meaningful action and being effective fig 3 mental models influence our perception of what is going on and guide our actions meaningful action implies that people feel listened to and respected even if their wishes are not met the sense that one is making a difference can go a long way towards bringing out the best in one 53 being effective concerns effectiveness and reasonableness because of mental fatigue it is about a particular aspect of mental functioning described as directed attention caused by the many complex and competing demands in ones environment the rpm framework will be used to study the way in which the physical environment can be health supportive to the inhabitants both spt and rpm put great importance on the interaction between the environment and the behavior of an individual they are complementary as spt focuses on the social environment and rpm on the natural environment within the extended network that exists in voorstad intersectoral collaboration is facilitated by a small steering group of partners from the healthcare and societal sectors with health brokers as essential participants this group can be regarded as the healthy alliance the updated hall framework will be used to study intersectoral collaboration within the healthy alliance in vom fig 4 this framework recognizes three groups of factorsinstitutional factors personal factors and the organization of the alliancethat can either facilitate or hamper the collaboration between the partners in the alliance 33 the updated hall framework visualizes the importance of context and learning culture in intersectoral collaboration 54 methodsdesign study design the study will use a mixedmethods design and will combine qualitative and quantitative data the research activities will include literature study indepth interviews focus group discussions concept and capacity mapping document analysis and analysis of citizens survey data table 1 the use of multiple strategies and multiple research methods across multiple levels is assumed to be the most effective approach the combination of fig 2 the elements of a social practice adapted based on shove et al 51 information from multiple sources and methodstriangulation increases data validity 55 also partners and citizens will be involved in the planning of the research as well as in different research activities a prominent strategy is action research which aims to involve all stakeholders capturing the different perspectives of citizens and professionals and engaging citizens with low ses the value of action research is that it reflects the values of health promotion such as participation and empowerment 6 56 57 58 it thereby facilitates the development of capacities learning and empowerment 4 and thus contributes to health 59 it also enables those involved to continually optimize their strategies 60 61 62 and it contributes to developing both fig 3 the reasonable person model 52 fig 4 the updated healthy alliance framework 54 translated from tol et al 54 prettys participation ladder 34 empowerment checklist 74 health literacy questionnaire 71 100 inhabitants 2 rq3 mechanisms hall framework document analysis interviews checklist coordinated action checklist 48 participatory network mapping tool 60 network analysis tool 60 12 professionals 68 network partners theories and research methods to understand and explain what works and why it works to operationalize and to provide insights into factors relevant to addressing the rqs the logic model based on the framework for planning implementation and evaluation of health promotion programs 63 will be used fig 5 this logic model will help to make explicit the hypothesized pathways to define processes output and outcome indicators at different levels and to unravel action elements 3264 figure 5 illustrates the logic model for the impact evaluation of vom based on literature on communitybased approaches 63264 and evaluation studies of complex community health promotion programs 64 the hypothesis is that a communitybased participatory approach to developing and implementing health activities at different levels such as individuals professionals and community will result in improved perceived health a health supportive environment and sustainable local health policy leading to a reduction in health inequities in the long term these longterm expected outcomes will be preceded by measurable shortterm outcomes like eg health literacy healthy alliances and changes in the physical environment moderated by the action principles in this model citizen participation intersectoral collaboration and a health supportive environment are defined as program outcomes and at the same time are action principles in this principlebased health promotion program 32 the operationalization of each of the four research questions is now set out research question 1 how do voorstad inhabitants perceive health and a health supportive environment perceptions on health and health supportive environments will be measured using focus groups and photovoice a collecting and discussing the perceptions and priorities of the inhabitants about health is the starting point for citizen participation in the vom program at the start of the program focus groups will be held with 15 existing groups of inhabitants to explore perceptions and meanings about health 6566 results of the first focus group session will be fed back to and discussed with the same group in a second session participants are challenged to think of actions and plans to work on their own health in total about 100 inhabitants will participate in this research study b photovoice will be used to reveal inhabitants perceptions of their neighborhood as a source of health opportunities or barriers 67 68 69 in total 3240 inhabitants will be asked to tell the story of the photo or image research question 2 what benefits do citizens who participate in the voorstad on the move program observe in terms of perceived health health literacy and empowerment active participation in health promotion activities varying from consultation and collaboration to partnership or ownership can either result from the focus groups or otherwise be initiated by the vom health brokers or collaborating partners a total of 100 inhabitants who either participate in focus groups or are involved in community activities will be followed during the program they will be asked about their way and level of participation using prettys participation ladder 3470 health literacy using the 9item health literacy questionnaire 71 72 73 and empowerment using the netherlands empowerment checklist 7475 perceived health is assessed based on the question on selfperceived health how is your health in general which contains five answering categories 1 very good 2 good 3 fair 4 bad and 5 very bad this question is part of the citizens survey which takes place every two years in deventer 16 and of the health monitor conducted by the municipal health services in the netherlands 7677 subsequently indepth interviews and focus groups will be held to discuss citizens perceptions on the connection between participation perceived health and empowerment research question 3 what factors and mechanisms contribute to citizen participation and intersectoral collaboration the hall framework will be used to study the intersectoral collaboration and active involvement of stakeholders and to identify conditions that contribute to the collaboration and make these alliances successful 3354 fig 4 a special focus will be placed on the role of health brokers as these seem to be crucial for connecting different sectors 78 the coordinated action checklist 48 will be used to evaluate and facilitate the collaboration of the core stakeholders members of the voorstad social team the neighborhood manager health brokers and the program coordinator the results of the checklist on various dimensions such as task relations growth and visibility will be discussed with this core group these evaluation sessions will be held once a year in total three times a document analysis of all the reports plans and notes produced by the project team will be used to describe the collaboration processes that have taken place furthermore a network analysis 3560 will be conducted to map the collaborating organizationscommunity centers schools grassroots organizations and neighborhood sports clubthat take part in the program irregularly and on a less structured basis five to 10 organizations will be interviewed twice to get insights into the impact of vom the collaboration processes 79 and the health broker role research question 4 what is the overall impact of the voorstad on the move program in terms of health promotion activities social and physical environment and inhabitants perceived health results and outcomes of the program will be measured on different levels individual professional and community fig 5 at the individual level perceived health lifestyle and health behaviors have been or will be measured in the local citizens survey every two years 16 additionally the health monitors 76 carried out in 2016 and 2020 will provide more detailed information on the health status of the city district voorstad in both surveys citizens health and lifestyle data are monitored at neighborhood level the program activities are monitored in a socalled activity database the number and type of health promotion activities developed with citizens involvement and the number of participants per activity will be registered thereby monitoring the program output citizens who participate in the program activities will be asked about their satisfaction in order to map changes in perceptions of the social and physical environment the photovoice study will be repeated in 2019 qualitative research data from interviews and focus group discussions will be audiotaped transcribed and analyzed using atlasti to manage the data and guarantee transparency a coding scheme based on theory and the framework will be developed to analyze the qualitative data stepwise data driven and thematically topdown as well as bottomup coding will be used the topdown coding will use predefined codes based on factors mentioned in the theoretical models the hall framework spt and rpm the bottomup coding will trace general themes that emerge in interviews and focus groups in this way relevant topics devised in advance of the study design and relevant topics from practice will be fully mapped these themes will make it possible to interrelate and interpret the gathered data 80 quantitative data will be analyzed by descriptive statistics and regression analysis techniques using the spss program in the analysis quantitative data obtained to measure changes in perceived health will be combined with qualitative data on participation empowerment and health literacy with data at professional levelshortterm outcomes realized by the healthy alliances and health brokers and with data at community levelthe social and the physical environment the impacts on the different levels will be integrated and related to the action principles using realist synthesis 81 in the data analysis facilitating the identification of the contextual factors and program mechanisms determining the outcomes these contextmechanismoutcome configurations 18 will provide insights into the overall impacts in relation to the action principles sample size and power the perceived health of adult inhabitants in the neighborhood will be used as the primary outcome of the vom program at the individual level in line with common practice in presenting perceived health prevalence rates response options for selfperceived health will be dichotomized with the response categories very good and good into one very good or good category and the other response options in a less than good category 82 in 2015 the percentage of inhabitants in the city of deventer scoring good health was on average 79 whereas this was 75 for the city district voorstad 16 therefore the estimate of the effect size of perceived health to be obtained by implementing the vom program was determined by the difference between voorstad and the city of deventer 004 the sample size calculation was conducted with g power version 3192 with alpha set on 005 and a power of 080 the used test family was exact and based on the difference from a constant the required lower critical number of participants is 542 the required sample size is 697 the response rate of health monitors in general is 40 83 as there are differences in response rate between city districts we assume a modest response rate of 35 the required number of participants to obtain reliable estimates of increase in perceived health is therefore 2000 the total adult population in voorstad is 8412 inhabitants 2200 inhabitants will be invited to join the online survey in order to be sure of sufficient power discussion relevance this study will evaluate the impact of a communitybased health program in a socioeconomically deprived city district in order to find keys to reducing health inequities it is a single case study in which low ses inhabitantsin the view of health professionals usually hard to reach and not very interested in health promotion activitiesare actively involved it will provide insights into perceptions values and needs regarding the health of low ses groups the vom program is innovative as it is different from usual health promotion programs in which health subjects and activities are set by professionals instead the vom program shifts from being a predevised health promotion program with a set of interventions to being an open approach with a focus on action elements unravelling the mechanisms of these action elementscitizen participation intersectoral collaboration at community level and a health supportive environmentwill help to find ways to reduce health inequities the findings will contribute to a better understanding and will expand the knowledge of what works for low ses groups and why it works other local health promotion programs can benefit from the knowledge and experiences gathered in this study strengths and limitations the study design is optimized for internal and external validity because of the combination of action research process evaluation and citizens monitoring and survey data the principle of triangulation is continuously applied to optimize the reliability of this study using multiple methods and multiple sources internal validity is enhanced by triangulation of methods and resources whereby results will be checked with other stakeholders in addition other verification techniques will be used such as expert consultation in this study the inhabitants survey will be used to measure perceived health and health determinants in a pretestposttest design the results obtained from these surveys will be linked with results from the intervention the environment and the organizational level in order to be able to explain why changes in perceived health have taken place or not the application of spt the hall framework and rpm provides the researcher with a strong theoretical framework and guarantees validation of the results gathered in this single case study this study contributes to the knowledge on the benefits of citizen participation being a necessary aspect of health promotion and how to realize it recent studies 84 recommend evaluation of community participation in creating a health in all policies knowledge base hence the participatory action research in itself contributes to health literacy is empowering for those who participate and contributes to community building 27 availability of data and materials not applicable competing interests the authors declare that they have no competing interests

background voorstad on the move vom is a community health promotion program implemented in a socioeconomically deprived city district in the netherlands based on exploration of the health situation concurrent views on health promotion and insights from literature vom is grounded in a socialecological perspective and puts three action principles center core citizens participation intersectoral collaboration and a health supportive environment vom aims to improve the health of inhabitants mostly low socioeconomic status ses families and to realize changes in the social and physical environment this current research as part of the wider vom project aims to study the impacts and action principles of vom the main research questions concern the inhabitants perceptions on health and health supportive environments the perceived benefits of citizen participation in terms of health literacy and empowerment and the factors and mechanisms that contribute to citizen participation and intersectoral collaboration methods the study has a mixed methods design including process evaluation and monitoring and combines qualitative and quantitative data research activities include literature study indepth interviews focus group discussions concept and capacity mapping document analysis and health survey data a prominent strategy is action research which aims to involve all stakeholders capturing the different perspectives of citizens and professionals and engaging low ses groups the principle of triangulation is continuously applied to optimize the reliability of this study using multiple methods and multiple sources internal validity is enhanced by triangulation of methods and resources other verification techniques will also be used such as expert consultation discussion the design of the study with a strong focus on action research facilitates the involvement of all stakeholders and contributes to the development of capacities learning and empowerment and thus contributes to health the vom program is innovative because it adopts an open approach in which activities evolve from citizens needs with a focus on action elements this study will unravel the mechanisms of the action elements at community level thereby helping to find ways to reduce health inequities the findings will further elucidate what works and why it works for low ses groups

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suggests that family wellbeing interventions are having a positive impact and promoting change in the lives of participants their families and their communities hence for complex interventions such as those with indigenous populations evidence should demonstrate effectiveness against prescribed outcomes as well as critical aspects behind how and why a complex intervention was successful keywords family wellbeing aboriginal health social and emotional wellbeing phased interventions best practice is to develop interventions systematically using the best available evidence and appropriate theory then to test them using a carefully phased approach starting with a series of pilot studies targeted at each of the key uncertainties in the design and moving on to an exploratory and then a definitive evaluation policy decisions should be based on evidence that demonstrates the effectiveness of interventions however the quantity and type of evidence that best supports the effectiveness of an intervention is not universally agreed upon and at times the evidence is not available generally the strongest evidence is demonstrated through gold standard research interventions most notably the randomised control trial policy decisions based on strong evidence are increasingly more desirable as decisionmakers operate in risk adverse public policy areas and have public accountability yet in areas of complex public policy such as indigenous health waiting for the right type of scientific evidence while other specialist knowledge is available could be harmful perverse incentives contrary to the decisionmakers desired outcomes may occur where inaction results in continued or escalating poor health outcomes public health policymakers attuned to the precautionary principle need to consider how to account for growing complexity and uncertainty where complex interventions cannot provide the preferred gold standard evidence the concepts of precaution and prevention are at the heart of public health policy where identifying and avoiding risks is as critical as identifying and implementing protective measures who explain that in the past public health interventions focused on removing hazards that had already been identified and proven in contrast as potential risk factors increase in complexity the precautionary principle seeks to tackle uncertain risk hence changing how science informs policy thus this a c c e p t e d m a n u s c r i p t paper in focusing on a complex situation explores alternative approaches for the provision of quality evidence to support decision making vujcich rayner allender and fitzpatrick demonstrate this principle emphasising that at times policy makers must make policy decisions in the absence of strong evidence particularly in circumstances where a lack of action is sociopolitically unacceptable this is particularly the case where practical constraints often make gold standard research methodologies impractical such as a rct in australias northern territory where a population level intervention would have required a sample of 30000 indigenous people which in that context was impractical in their examination of the indigenous tobacco control initiative vujcich et al found that policies were not made recklessly instead evidence from other settings and expert opinions were considered to generate conceptually plausible policy responses aligned to the preferences of members representing indigenous communities furthermore they found that e vidence cannot trump all other factors rather it must coexist with other inputs in the policy process which includes the consideration of the needs of the target population similarly hudson reported that o ne of the reasons given for the low return on indigenous investment is that the money is not going to where it is needed most or used in ways that respect indigenous input into program design and delivery therefore hudson there are circumstances in which it may be justifiable to enact interventions in the absence of gold standard evidence in such circumstances a better approach is to start with the available evidence scientific and valued by indigenous people and incrementally strengthen the evidence base though approaches that provide complementary evidence such as continuous quality improvement systematic reviews and reviews of reviews reveal the variety of ways in which programs and services can be rated for effectiveness and impact while gold standard evidence is being sought for policy decisions the path to such evidence should be suitable to the context and target populations often systematic reviews use study quality assessment measures developed in the clinical context and may be less suitable for evaluating the impact of interventions which have the complexity of psychosocial interactions moreover when working with indigenous populations appropriate interventions must include indigenous perspectives in the planning developing implementation and evaluation stages if the desired outcomes are to be achieved qualitative a c c e p t e d m a n u s c r i p t evaluations align with indigenous traditions of storytelling yet such approaches do not necessarily generate the evidence for policy decisions where more objective measures are preferred as such research techniques that endeavour to interrogate qualitative data to provide evidence of impact beyond narrative and thematic analyses are beneficial therefore a detailed review of valued indigenous interventions is needed so that the uptake of programs that indigenous people believe have impact is not constrained by the lack of the type of evidence required by decisionmakers while the requirement for quality evidence and associated research impact is inevitably increasing there are challenges in determining the appropriate methods and indicators for assessing research impact particularly the attribution of a given outcome for a given intervention hence developing such evidence requires time so it is also imperative that interventions are sustainably supported while incrementally improving the evidencebase one intervention program that has sought to address the challenges of social health research in providing evidence of impact is the family wellbeing empowerment program which has adopted a phased approach to evaluating complex interventions family wellbeing empowerment program the family wellbeing empowerment program was created by a group of stolen generation indigenous people who felt that indigenous people and families needed support in developing the skills and capacity needed to face the daily challenges of being relatively marginalized minority peoples in a highly affluent australian society hence the program addresses socioeconomic disadvantage and health inequality through fostering personal empowerment social cohesion and community connectedness from modest beginnings in 1993 the program developed into a flexibly structured group learning experience combining indigenous survival experiences and psychosocial holistic approaches for health and wellbeing into the four stages of fwb foundations in counselling coping with grief and loss changing and working together and moving forward while fwb has been the subject of ongoing evaluations these have generally been qualitative focusing on individual perceptions of change and were necessarily based on small sample sizes more recently mixed methods evaluations have been conducted however these are also based on selfreported data from small samples consequently the strength of the evidence of impact is often dismissed as insufficient to link the intervention directly to positive outcomes the adoption of approaches to synthesise similar inventions to provide stronger evidence for impact highlights the complexity and additional challenges in establishing strong evidence for the effectiveness in social health research efforts to review and synthesise fwb research to date by tsey et al were in essence a review of the evidence being carried out by researchers already familiar with the intervention hence the aim of this review was to collaborate with independent a c c e p t e d m a n u s c r i p t researchers who have not been involved directly in fwb interventions to 1 lead a review of characteristics of the fwb evaluation output to date and 2 to assess for evidence of the fwb interventions impact on participants and their communities in leading the review these independent researchers developed the inclusion criteria conducted the article selection analysed the characteristics of the selected articles developed the matrix protocol and analysed the data to populate the matrix all three authors contributed to the development of the program logic the discussion section and the explanation of the implications for future research in this area in this review we propose that while policy makers need rigorous evidence to support decision making such evidence is not always available due to ethical cultural and practical situations furthermore indigenous issues require indigenous involvement and indigenous perspectives to ensure that policy decisions and strategies address the real issues as identified by indigenous people therefore a way forward is to conduct research where multiple sources of evidence are collected and analysed to develop a rich picture of the situation and opportunities for data triangulation from multiple sources this approach offers more than the sum of the quantitative and qualitative evidence the synthesis can provide more depth which is likely to improve understanding and support implementation thus this review uses practical solutions to achieve outcomes that increase the evidencebase which is more pragmatic than demanding the perfect evaluation which cannot be delivered method a literature review was conducted in a manner consistent with the prism statement this used the search term family wellbeing program and aboriginal using one search which searched multiple databases including informit cinahl ebsohost ovidsp ovidmp pubmed proquest and the wiley online library the 2982 matches were screened by title and abstract against the inclusion criteria below figure 1 approximately here inclusion criteria for the review of characteristics of the fwb evaluation output to date 1 the primary focus of the paper was improving health and wellbeing outcomes through a fwb intervention or 2 the paper contains a multicomponent study that includes health and wellbeing outcomes for a fwb intervention and 3 the paper was published or prepared for peerreview publication a c c e p t e d m a n u s c r i p t additionally nine papers were identified from key authors in this field that were under review or prepared for publication at the time of writing this article following screening 63 papers were included in the full paper review with 48 papers selected for inclusion in this review the review commenced with an analysis of the broader characteristics of the publications data analysis was conducted using microsoft excel and ibm spss 23 next the program logic framework was used which draws on the underlying assumptions for the fwb program to define the needs resources activities outputs and outcomes of the fwb intervention providing the logic to the anticipated outcomes and outcome usage beyond the program program logic enables researchers to consider the logic of the progression of a program from needs to outcomes and can assist the development of strategy and policy inline supplementary figure 1 approximately here the fwb program responded to a need identified by indigenous australians and particular inputs and resources are required for the intervention through the program logic it is apparent that the inputs and activities result in a range of outputs and program level outcomes as well as outcomes beyond the project level this program logic then guided the exploration of the evidence with the results section examining evidence of engagement and impact in the selected publications this evidence is reported using the source of identified needs funding sources industry engagement research design and methodology outputs and outcomes to structure the findings figure 2 approximately here it was evident from the identified studies that a larger proportion were based on qualitative than quantitative techniques constraining the development of a synthesis of impact to best capture the information from the analysis the subsequent analysis for evidence of the fwb interventions impact on participants and their communities used a subset of papers for more indepth consideration regarding impact using the following inclusion criteria 1 the paper included empirical research that collected data from and 2 the paper was an evaluation including demonstrated experience where the publication reported on the impact of fwb on the authors own life which is in itself was evidence of evaluation and economic evaluation a c c e p t e d m a n u s c r i p t this process left 29 papers identified for further assessment of intervention impact both quantitative and qualitative studies reported on smaller pilot studies but the latter provided rich indepth assessments of programs and thus gave insights into the how and why impacts from the interventions occurred it was apparent that a strategy was needed to synthesise the largely qualitative evidence into more objective measures without compromising the richness of the qualitative studies to enable comparison with the quantitative studies two tools that assess impact and change blooms taxonomy and the prochaska and diclementes stages of change modelwere used to assess the reported findings in each publication for evidence of positive change from the intervention attributed to the fwb program inline supplementary table 1 approximately here blooms taxonomy is a widely used hierarchy from lowerorder cognitive processes classified as remember understand through to higherorder cognitive processes such as apply and analyse evaluate and create prochaska and diclementes stages of change model moves through six steps from precontemplation contemplation preparation action maintenance and then relapse prochaska and norcross report that this model has been widely used to explore behavioural change over a 20 year period and campbell et al used prochaska and diclementes model in their study with indigenous australians to examine the impact on health promotion programs on tobacco smoking cessation firstly each paper was assessed against the four blooms taxonomy levels for the key dimensions of the fwb stage one program leadership basic human needs relationships life journey conflict resolution understanding emotions dealing with crises beliefs and attitudes following this step using the same coding methods the publications were then assessed against the six stages in the prochaska and diclementes stages of change model from this a matrix presenting the evidence of impact from the learning and change indicators was produced to identify publications that reported evidence of both learning and change inline supplementary table 2 approximately here inline supplementary table 3 approximately here results characteristics of the studies a c c e p t e d m a n u s c r i p t an examination of the selected publications illustrates the breadth and depth of the research on fwb and demonstrates a continued research effort over a 17 year period using sansonfisher et als classification of publications the majority were original research with the remainder classified as case studies and program descriptions the publications provide an account of the development adaptation and impact of an intervention program developed by indigenous people that inclusively enables indigenous participants organisations and researchers to collaborate with universityresearchers the universitybased researchers were affiliated with 12 different universities in a variety of contexts and locations in four countries australia png china and timor leste the majority of the australian research sites were in queensland northern territory victoria and new south wales with remainder not citing a specific location inline supplementary table 4 the interventions varied with the scope of the fwb intervention ranging from a 1day workshop to an accredited certificate iii in fwb sample sizes ranged from 1 to 158 with the average sample size being 33 participants participants were aged from 960 years there were mixed groups of both male and female participants and genderspecific groups overall where the gender of participants is reported there were more female than male participants most frequently the publications reported a fwb stage one intervention and versions of the stage one intervention tailored to meet group needs there were 34 papers that contained details about participant groups to whom fwb has been delivered community service employees residents of indigenous communities fwb facilitators and researchers university students young people users of community services mens groups school children and department of education employees approximately onequarter of the papers reported findings from pilot studies suggesting cqi approaches were used to incrementally build evidence less than one third of the papers contained data that was collected postintervention and of those that contained postintervention data almost half were published since 2015 the duration post intervention for data collection ranged from immediately after the completion of the intervention to more than one year later one study intended to collect postintervention data however were unable to collect the data due to a lack of dedicated evaluation resources to engage and negotiate followup data identified need the evidence of engagement usage and impact for fwb interventions is outlined in this section as well the inputsresources and activities sections a c c e p t e d m a n u s c r i p t table 4 most interventions involved 2140 hours some were more than 40 hours and few were less than 20 hours one quarter of the papers did not state the length of the intervention instead they reported that they delivered fwb stage one or an adapted version of fwb finally two papers reported on participants who undertook accredited training and two papers reported on fwb as it was integrated into university curriculum outputs the first publication was in 2000 with consistent publications since 2003 and a sharp increase from 20092011 analysis revealed that the increase was consistent with an increase in research activity associated with increased funding and an industry partnership during this period there also has been a shift in study type from the initial qualitative research while the greater majority of papers reported on qualitative studies the first of the three quantitative studies commenced in 2010 then 2015 and one in preparation for publication one mixed methods study was published in 2009 however the majority of such studies were more recent or are yet to be published figure 3 approximately here outcomes publications reported positive outcomes through statistically significant changes in selfreported quantitative data or by referencing stated observations of changes in selfreported qualitative reports a selection of the evidence suggesting that fwb had a positive impact is presented below participants and fwb facilitators directly attributed change to the fwb program that they attended or facilitated with comments recognising this change i am a changed person because this course helped me to evaluate myself and at the same time has empowered me to do more for other people fwb has given me a strength to identify real needs in the community others recognised their ownership of this program and how it has moved their perspectives our mob when they hear that its been developed by our own people thats the only reason why sometimes i think they come along to it so i think thats the most critical thing and that it works of course but you know people dont know that its going to work until theyve done it a c c e p t e d m a n u s c r i p t why didnt i do this sooner we actually find ourselves beginning to live fwb it is something that you are doing you are teaching that to people but you are actually living it doing fwb has taught me skills that enabled me to realise that i need to meet my own needs i need to look after myself rather than looking after everyone else…i wanted to stop feeling like i was a victim i wanted to stop taking on board other peoples problems when it wasnt my problem i wanted to be more assertive not to be demanding i wanted a good home life i was depressed sometimes now when this happens i can examine whats making me feel like that i needed to learn to look after myself the quantitative and mixed methods research studies piloted research tools including the development and validation of a research tool the growth and empowerment measure specifically designed to measure impact for indigenous populations other studies used validated measures such as versions of the kessler psychological distress scale the australian unity wellbeing index and questionnaires designed to measure change in social emotional and physical health several quantitative and mixed methods studies identified evidence of significant positive impact for example whiteside et al reported that the k5 showed a highly significant reduction in psychological distress across the time of the study 367 p 003 with a very strong effect size kinchin et al found positive change for participants postintervention reporting that the gem responses on selfcapacity inner peace strength happiness and connectedness indicated a 17 positive change in the mean scores and that for the auwi the most satisfactory postinterventional response was provided on future security which was estimated even higher than the national benchmark lui et al found evidence of fwb program impact in the fwb study conducted in china reporting that all aspects of the wellbeing scores before and after the training significantly improved in both rounds of data collections in addition they found that the means for the leadership scores were highly significantly different before and after the training in both round of data collections a c c e p t e d m a n u s c r i p t assessing impact and change the assessment of impact and change was undertaken on the 29 identified papers using blooms taxonomy and prochaska and diclementes stages of change model with scoring used to capture evidence of positive change identified through the research for example in a quantitative study the identification of a statistically significant change in participants satisfaction with life provided evidence of impact for a positive change in beliefs and attitudes similarly in a qualitative study a story describing how a participant came to see that to every problem you find a solution you can achieve whatever you want to in life provided evidence of impact for a positive change in beliefs and attitudes following the assessment of all papers the highest score for each measure was identified from the eight different dimensions of fwb leadership basic human needs relationships life journey conflict resolution understanding emotions dealing with crises and beliefs and attitudes assessments this recognised the level of change observed on one or more of the eight dimensions of fwb from this the publications fall into two distinct categories summarised in figure 4 group 1 with low scores and group 2 with high scores group 1 contained 13 publications the majority of which were qualitative and the remainder were mixed methods studies group 2 contained 16 papers once again the majority were qualitative however there were also several mixed methods and one quantitative study the publications that scored the highest across both measures provide interesting results for how we consider fwb impact four publications reported findings from qualitative studies that analysed data from indepth interviews reflective diaries and existing documentation and three were written by indigenous authors interestingly this synthesis revealed that evidence of impact in terms of comprehension and behavioural change was more likely found in the qualitative studies figure 4 approximately here figure 4 reveals that 28 publications contained evidence of comprehension with the highest mean score for the publications translating into evidence of impact in order of hierarchy with evidence that participants remembered understood analysed and created which they attributed to the fwb program similarly there were 22 publications that revealed evidence of change with 77 containing evidence of action 9 containing evidence of preparation and 14 containing evidence of contemplating change a c c e p t e d m a n u s c r i p t overall the review of the publications suggests that a staged approach to evaluating complex social interventions can provide evidence of program impact for participants their families and communities the results presented in this section provide a picture of the development and growth of an intervention that has systematically built an evidencebase over many years often using cqi approaches such as participatory action research and pilot studies discussion the innovative approach used in analysing the data to assess the impact and change evidence from fwb interventions provided insights that extended from the original papers and synthesis of the studys characteristics this approach revealed evidence of action that is evidence of participants actually using the knowledge and skills developed from the intervention in their lives at the time of data collection further the four papers that scored highest on blooms taxonomy and highest on prochaska and diclementes stages of change included postintervention data thus contributing to the argument that to demonstrate impact sufficient time must pass between the intervention and the postintervention data collection to allow participants an opportunity to change while this review revealed that continuous staged evaluation of fwb over seventeen years has provided evidence of its impact it also highlighted further considerations for use and interpretation of findings and also future research design to contribute to enhanced evidence from such studies we posed the question how much evidence is needed to secure the confidence of policymakers to support complex interventions that report positive results over a long period across varied populations where access to culturally appropriate interventions is limited as this review revealed in addition to the usual practical and methodological difficulties many of the added challenges for interventions as seen with fwb are associated with the difficulties in obtaining sufficiently sized samples of comparable data to demonstrate impact the review findings highlight the range of studies conducted over the 17 year timeframe and while the cqi and phased approaches have supported the growth and increased sophisticated in evaluation methodologies during the period an absence of consistent reporting of aspects of the research was seen further the variety of data collection tools used reduces the benefits that a synthesis can bring to providing evidence of intervention impact while the key consideration when evaluating complex interventions is pragmatically more about practical effectiveness thus whether the intervention works in regular practice benefit is seen in researchers using a standardised set of core measures to enable comparable data to be analysed from small interventions to support the development of a robust evidencebase for complex phased interventions across multiple locations this would contribute to the evidence of impact beyond the programlevel where evaluating the effectiveness of an intervention is important to our understanding a c c e p t e d m a n u s c r i p t about how the range of effects of the intervention vary over time and between locations as well as the causes of that variation the review revealed that for phased interventions such as fwb mixed methods research may contribute to strengthening the evidence for impact that satisfies funders researchers and target populations while continuing to collect the rich qualitative data for example a standard set of questions which would contribute to a set of core measures used across all interventions in terms of the fwb program the findings from this review suggest that a standard set of core measures including the kessler psychological distress scale australian unity wellbeing index and a small set of common questions to address key indicators that reflect changes in behaviour would provide more consistent findings from each small study to be synthesised to provide more understanding of the impact beyond each individual program additionally it would be valuable for researchers to access publicly available community level data in factors such as school attendance or child welfare notifications before and after interventions as an additional measure of change with policy makers requiring more evidence from research using methodologies more suited to medical research it can be difficult for social health research which uses more qualitative methodologies to develop an evidencebase that is judged sufficiently rigorous to attract similar support and funding hence this approach would enable the flexibility for each pilot study to tailor and adapt the evaluation using cqi approaches based on context and purpose of the intervention while at the same time developing a larger quantitative dataset to analyse all of which builds evidence for the impact of fwb while maintaining the integrity of the intervention in their investigation about how research evidence influences health policy decisions vujcich et al report that their literature review found that most studies had methodological limitations and that few studies used empirical evidence to demonstrate why evidencebased policy making is superior to other forms of decisionmaking furthermore there can be negative implications from decision making relying on for example gold standard evidence vujcich et al explained that when applied to a context such as indigenous tobacco control the position that there should be no policy without evidence could feasibly have resulted in a widening of the health gap between indigenous and nonindigenous australians simply because there was more research to demonstrate the effectiveness of interventions in the latter population moreover birch describes the paradox of this approach where a lack of evidence of effectiveness restricts resources to a disadvantaged group thus reducing the resources available to provide evidence of effectiveness and further disadvantages the group who were the target of the initial intervention where effectiveness is demonstrated in a mainstream less disadvantaged population resources are redirected to the population where the evidence of effectiveness can be demonstrated ultimately this contributes to further social inequalities in the health of the disadvantaged population irrespective of what is deemed to be sufficient evidence for decisionmakers and academics alike the demand for fwb remains strong in fact the demand for fwb which arises from indigenous people completing the fwb program and subsequently suggesting that friends and family do the program as well results in strong support for the fwb intervention at an individual organisational and community level furthermore the spread of fwb internationally together with the demand for fwb across australia clearly shows the extent to which indigenous people are willing to vote with their feet in order make a program that they value available to themselves with increased demand for available resources it is essential that resources are focused in areas that are not only perceived as important for indigenous populations but also are demanded and deemed to be effective by the same populations to date the success of fwb is in part driven by the fact that participants encourage others to attend and find ways for fwb to become part of their community andor workplace there is undeniably consumer demand for fwb surely an essential first step in any intervention program hence strategies are necessary to enable and support implementation and upscaling of programs that work such as fwb which will require a rethink of the way in which decisionmakers view the evidence that shows that a complex intervention is effective lessons learned mapping the way forward complex intervention programs such as fwb need strategies to build evidence for their effectiveness appropriate to the context of the intervention as such it is unlikely the future evidence will be in the form of large scale quantitative studies or rcts for the reasons explained earlier in this review therefore it is imperative that researchers undertaking complex interventions conduct and publish evaluations so that a stronger evidencebase can inform a more strategic way forward for implementing sustainable complex interventions future strategies that could improve the available evidence about the effectiveness of complex intervention should include  longitudinal studies that can provide evidence about long term change resulting from the intervention  more consistent reporting of funding and inkind support for the intervention  a more structured approach in the development of evaluation tools for collecting quantitative data so that the data from multiple studies can be synthesised and analysed this would enable data analysis with larger sample sizes and may enable comparisons with other datasets such as routinely available data  more focused effort in reporting attribution of the intervention for impact at both a program level and beyond the program level and a c c e p t e d m a n u s c r i p t  recognition that for social interventions the benefits may not be seen for months or years after the intervention particularly where there is a focus on improving impact through engaging and partnering with indigenous populations and industry consequently funding should be allocated for the development and engagement costs for interventions that are required prior to the research being conducted and for post intervention research to capture impact months and years after the intervention if the population level impact of the intervention is to be reported in addition the cqi approach of staged evaluation and building feedback into future iterations of the programs is a sensible path to building robust evidence however this approach takes time and needs commitment from governments as well as university and industry partners as it often does not generate the positive results against quantitative indicators in the shortterm that constitute the preferred evidence for reporting on intervention impact limitations there was a limitation in that the majority of the research conducted has been qualitative with selfreported changes attributed to fwb quoted as evidence of fwb impact the validation of research tools and use of independently developed scales were increasingly used in the most recent publications suggesting that while selfreported data remains a limitation the studies are now incorporating widely accepted robust scales into data collection tools the wide variation in the scope of the intervention is also acknowledged as a limitation however the customisation of the fwb intervention which is tailored according to need means that the scope of the intervention may not be as important as the quality thus a focused brief intervention may meet participants needs as well as a generic twoweek intensive certificate course furthermore there was evidence of impact in publications that reported brief interventions as well as accredited certificate training hence while scope of intervention is acknowledged as a limitation it was not believed to be sufficient to influence the findings from this review while the synthesis aimed to treat the qualitative and quantitative data in a similar manner to aid comparison differences in the publication type and style are acknowledged as a limitation for this review in particular some publication types for example reports books and longer journal articles provided more opportunity to present evidence this review did not count the frequency of evidence it was either present or not which minimised the influence of publication type and style however it remained a limitation for the review conclusion where it is not appropriate or viable to conduct research such as rct that provides evidence at the level preferred by decisionmakers alternative ways of providing evidence for effectiveness of an intervention is vital this review suggests that fwb is having a positive impact and promoting change in the lives of participants their families and their communities therefore it is reasonable to continue by using the available evidence while continuing to evaluate and implement recommendations to provide a deeper understanding of the long term benefits of fwb however to do this it is vital that decisionmakers understand the limitations in either the practicality or application of approaches such as rct assessments in some situations and thus recognise that where alternative research approaches are appropriate and methodologically sound it is sensible to continue to evaluate examine and interpret the available evidence through such approaches for complex interventions such as with indigenous populations evidence should demonstrate effectiveness against prescribed outcomes as well as critical aspects behind how and why a complex intervention was successful approximately half of the papers reported an invitation to conduct the research with many papers not explicitly stating how the need was identified also many described ongoing partnerships and that the research continued due to previous or current universityindustry partnerships suggesting that the ongoing partnerships were the conduit to continued research with these industry and community partners inputsresources four key authors were identified tsey whiteside mccalman and cadetjames these authors have consistently coauthored papers for more than ten years and have collaborated with many industry and university authors with 62 individual authors named across the publications while most of the authors were universitybased one third were from industry and more than half of these industry authors were indigenous overall one third of all authors were indigenous with five publications having an indigenous first author the analysis revealed that 65 of the papers reported financial support australian competitive grants other public sector research income and industry and other research income while only one third of the papers reported inkind support industry crc university this support came from 23 sources industry and crc activities purpose the fwbrelated activities were carried out for a range of reasons with most papers reporting the purpose was to address social health andor political challenges there were 32 papers that explained why fwb was delivered the most frequent purpose was empowerment followed by improving health and wellbeing improving employment outcomes addressing interpersonal violence addressing substance abuse developing resilience promoting suicide prevention and improving education outcomes the purpose of the research was also explored and while the reasons varied most frequently research was conducted to determine effectiveness build theoriesmodels evaluate impact describe the intervention assess feasibility in another context or to engage with industry scope of intervention the responses regarding the scope of the fwb intervention were quite varied there were 28 papers that described the scope these varying from oneday training to studies conducted over many weeks see inline supplementary declaration of interest the third author declares that they have received grants to conduct some of the family wellbeing intervention research evaluated in this study however there are no financial relationships with any organisations that might have an interest in the submitted work in the previous three years and no other relationships or activities that could appear to have influenced the submitted work empowermentbased research methods a 10year approach to enhancing indigenous social and emotional wellbeing australasian psychiatry 15 s34s38 tsey k travers h gibson t whiteside m cadetjames y haswellelkins m mccalman j wilson a the role of empowerment through life skills development in building comprehensive primary health care systems in indigenous australia australian journal of primary health 11 1625 tsey k wenitong m mccalman j whiteside m baird l patterson d baird b fagan r and wilson a a participatory action research process with a rural indigenous mens group monitoring and reinforcing change australian journal of primary health 10 130136 tsey k whiteside m daly s deemal a gibson t cadetjames y wilson a santhanam r haswellelkins mr adapting the family wellbeing empowerment program to the needs of remote indigenous school children australian and new zealand journal of public health 29 112116 vujcich d rayner m allender s and fitzpatrick r when there is not enough evidence and when evidence is not enough an australian indigenous smoking policy study frontiers in public health 4 references whiteside m tsey k cadetjames y empowerment as a social determinant of indigenous australian health the case of the family wellbeing programme policy press whiteside m tsey k cadetjames y a theoretical empowerment framework for transdisciplinary team building australian social work 64 228232 whiteside m tsey k earles w locating empowerment in the context of indigenous australia australian social work 64 113129

policy decisions are based on evidence that demonstrates the effectiveness of interventions however the quantity and type of evidence that is needed to demonstrate the effectiveness of an intervention is not universally agreed upon the aim of this study was to collaborate with researchers who have not been involved directly in family wellbeing interventions to lead a review of characteristics of the family wellbeing intervention evaluation output to date and to assess for evidence of the fwb interventions impact on participants and their communities the study found that where it is not appropriate or viable to conduct research such as randomised control trials alternative ways of providing evidence to demonstrate the effectiveness of an intervention is vital this review

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structuring roles and gender identities within families explaining suicidal behaviour in south india introduction understanding risk factors for suicide is not just an actuarial process but it is also about exploring the life process that leads to such decisions and actions this paper analyses how a series of life events and everyday situations lead men and women to attempt suicide while examining the interactions of culture structure gender and constantly structuring roles as both antecedents and explanations of suicidal intent and behaviour structuring roles in this paper refers to the process of constant changes between agency and structure in the formation and structure of an individuals roles within families and society the structure dictates a set of dispositions which has the power to generate and influence perceptions and practices of the present and the future the vast majority of existing literature concerning suicide in india has tended to focus on epidemiology and risk factors very limited attention has been given to understanding the influence culture plays in india suicidal behaviour receives biomedical attention rather than psychosocial interventions the national crime records bureau in india records statistics in relation to deaths through suicide however no records are kept in cases of attempted suicide according to their recent reports nearly 43 of suicides for the year 2013 were attributed to reasons such as family problems and illness but they fail to define or explain what constitutes family problems and how they might lead to suicides the epidemiological studies indicate a wide variety of reasons associated with completed suicides such as economic hardships including in rural agricultural areas relationship problems farmer suicides student suicides caste discrimination military suicides manuscript click here to download manuscript gendered roles in families explaining suicidal beahviourdocx alcoholism depression mental and physical illness most of these studies have used quantitative methods emphasising statistical analysis that are useful in helping to illuminate risk factors but do not offer an indepth exploration into risk factors from the perspectives of survivors these data predominantly provide epidemiological findings and reports from medicolegal autopsies very few studies have used qualitative methods to explore life situations of individuals who have experienced attempting suicide and few have sought to situate suicide within a cultural explanatory model the relevance of using qualitative methodologies is evidenced for example in staples ethnographic study of suicides in a leprosy colony of bangalore he recognised how social situations and cultural beliefs shared within the region posed a risk of suicide for young healthy men with parents affected by leprosy who held high aspirations but lacked opportunities and resources in line with the ncrb report the independent survey by patel and colleagues highlighted that male rates of suicide were higher than female rates in india however the overall rates for both male and female in the independent study were higher than those recorded by the ncrb this led to the conclusion that the national records underestimate male suicide rates by 25 and female rates by 36 it has been widely reported that the ncrb rates underestimate the true rates of suicide the reasons for this underestimation are thought to relate to the stigma and shame that families may face if the cause of death is reported as suicide equally the illegality of suicide in india also leads to many cases of suicide getting misreported as accidental death the variation in male and female suicde rates calls for a better understanding of gender dynamics from the perspectives of survivors and those who treat survivors of attempted suicide the overall aim of this study was to explore the cultural implications of attempted suicide and its prevention in south india the study aimed to achieve this by exploring the experiences of survivors of attempted suicide and perspectives of mental health professionals and traditional healers however in this paper we focus specifically on cultural dynamics within the context of family with specific reference to the cultural process and gendered notions that have implications for suicidal behaviour methods indepth interviews were conducted with survivors of attempted suicide mental health professionals and traditional healers in a range of urban semi urban and rural locations including bangalore mysore and kodagu districts in karnataka southern india interviews took place within the settings of a hospital clinic temple church office or home the survivors were sampled purposively within the age group of 1844years and inclusive of any gender religion caste and class regardless of schooling level means of livelihood and professional background the sample was accessed through mental health professionals who acted as gatekeepers the mental health professional participants were recruited purposively and included psychiatrists general practitioners psychologists and social workers the healers were sampled from hindu muslim and christian religions using a snow ball method with the help of previous users of healing services believers of services and personal contacts from across the karnataka region in south india it was important that participants understood and spoke either english or kannada to facilitate the interviewing process and obtain rich data the researcher rl is fluent in both informed consent was obtained from participants in writing or audio recorded in case of illiterate participants the conversational approach of the indepth interview method made exploring sensitive data possible which may have posed challenges if using structured methods the data were organised and analysed using constant comparison methods and thematic analysis at later stage bourdieus theoretical concepts such as doxa 1 cultural capital symbolic power and violence were used to interpret and test the findings through critical discussion of the data the first author who carried out data collection and analysis is a south indian woman and a registered mental health social worker in india she was therefore identified by participants to some extent as a cultural insider for being an indian national however she was also identified as a cultural outsider by some participants in that she did not share the religious backgrounds of some participants and her casteclasseducationprofessional identity set her apart from some participants being able to position both as an insider and an outsider facilitated this study to be culturally sensitive and provided a space for the voices of survivors to be heard alongside the voices of mental health professionals and healers who treat them results in this paper the data are discussed under the category of gender and role structures within families as these are the themes that emerged from the data the quotations from participants are used to illustrate their perceptions with regard to the themes under discussion gender and role structures within families 1 doxa refers to a deep system of beliefs that are naturalised through the process of unconscious mechanism where individuals accept and practice many things without even knowing them as though they were legitimate cultural prescriptions towards genderbased roles within the structure of family were a key focus in all three sets of data in particular the influence of gender assigned roles in causing distress and suicidal behaviour became repeatedly evident through the course of analysing participants accounts the survivor participants accounts revealed that the duality and polarisation of cultural practices subjected them to internalize cultural norms and made daytoday living with set boundaries challenging distressing and gradually contributing to suicidal behaviour for instance there were many examples of women survivors describing situations within their roles as a wife mother and daughter in which they felt forced to continue in the marriage for the good of children or to preserve parents reputation my mother got me married i didnt want her name to be spoilt i was young i didnt understand things these compromises often included being abused abuse included examples of domestic violence sexual abuse physical abuse sexual jealousy neglect and encouraging another individual to inflict torture on the victim in the healers and mental health professionals accounts gender roles and influences were also apparent in their explanations of clients attempted suicide however these were presented largely in terms of stressors furthermore the definition and interpretation of what was a genderrelated or rolerelated stressor usually reflected their own sociocultural religious economic educational and professional background for example healers associated most of the reasons with religious aspects such as lack of faith ill effects of magic spells rahu kala and evil effects on women during menstruation they also indicated that conflicts within families are a result of western influence which guide men and women to adopt new cultures and cultural behaviours our land is called a land of toil there is a system in the society especially the family system which we have inherited from our ancestors however the younger generation hardly follow these … they are driven by the foreign culture creating more desires which cant be fulfilled mental health professionals associated suicidal events with depression and other mental health conditions they explained challenges and frustrations experienced by their clients as a result of gender and family structures as precipitators of the presenting mental states …family members have complaints and the expectations are higher than what can be achieved this leads to increased levels of stress and women are victimised into abuse and torture most of the time both healers and professionals focused primarily on the immediate events that preceded the attempt abuse violence and torture within set boundaries the participants from all three groups discussed intimate partner and family member violence as the most common form of violence that affected survivors physical mental emotional and psychological wellbeing conflicts within families were a significant precursor of attempted suicide as also identified in epidemiological studies a deeper understanding of participants accounts revealed that an individuals gender role within a family had an influence on their behaviours and interactions with other members of the family for example certain roles within the family structure come with power through tradition and are often associated with responsibility most of the participants highlighted the cultural tradition of assumed roles and responsibilities that various members within a family share which is said to have assigned them with power as in the case presented by one of the mental health professionals in the following extract the mother and the brotherinlaw of the survivor who was under treatment felt it was their responsibility to get her married in order to secure her future even if this was against her wish her father passed away mother was managing the family and her brotherinlaw was taking care of the family needs her mother forced her to get married to another guy who was well off they tortured her and got her married family abuse in this case particularly mostly sisters husband uncles mamas they take right over the family they have asked them to listen to them the survivor participants accounts revealed instances of repeated violence perpetrated by their husband parentsinlaw and other members of the extended family one of the survivors explained that although she and her husband lived separately from her parents inlaw their interference and influence was persistent which impacted her relationship with her husband and resulted in more violence and abuse the data depict the exercise of power by taking on particular roles within the family there is a constant interaction between the structural settings which define an individuals position and orient perceptions and behaviours for example husbands and inlaws hold power and utilise this by control and domination demonstrating the interplay of power in this process through symbolic and physical violence where women are subjected to violence the findings revealed that gender and age were instrumental in determining who held power in the family however cultural capital opened up margins for manoeuvring field and agency that could be used to redistribute power according to assigned cultural roles as bourdieu explains power over social or physical spacefield comes from possessing various kinds of capital takes the form in appropriated physical space for instance despite being educated and employed female survivors translated their social position as a wife and daughter inlaw into being subjects of social and cultural domination which in turn left them with less power however there is a dichotomy where the position of the mother inlaw is in spatial opposition and is substantiated with cultural domination and power these oppositions are asserted in a social space of family with symbolic distinctions of cultural capital assigning power with this understanding of how culturally assigned roles share power and responsibility we now move on to explain how it varied for men and women that transformed everyday situations to stressful events leading to attempted suicide men and suicide the distressing nature of cultural expectations are clearly expressed through survivors accounts where male participants expressed how their identity of being a man husband and son was linked to economic responsibilities and professional success one of the male survivors was particularly distressed when he felt that his power and authority in the family was threatened when his wife took over the responsibility due to his failure to earn money and look after the family the participants from the mental health professionals group added to this by expressing that culturally it is unmanly for a man to express his emotions or cry and share his feelings this notion of masculinity leaves men with fewer options for support in the family and in society a similar finding was evident in staples ethnographic study where healthy young men from a leprosy colony in bangalore felt distressed when they failed to fulfil their responsibilities and lacked opportunities for employment healer participants expressed that stress among men and women is caused due to the changes in life style a desire for more wealth and unending demands of wives upon their husbands which contribute to men attempting suicide gender differences were particularly distressing for one of the survivors who was transgender and gay his situation worsened when no one in his family school community or friends understood him instead he was beaten up by his family for cross dressing and mocked in his school although there was a history of transgenderism in previous generations of the family it did not seem culturally appropriate to talk about this in the family or in public most survivors experienced stress and internal conflicts because of cultural expectations towards their roles as a husband son and a father the interplay of power in exercising each role was dynamic and was influenced by cultural practices and social norms roles as a husband son father are imbued with power that are based on practices gender and what is happening in the field of family this was challenging for survivor participants women and suicide for women survivors there was a constant struggle and conflict with self and their surroundings to reach the high expectations of being a perfect daughter wife daughter inlaw and mother the vast majority of survivor interviews contained accounts of abuse assault and torture within marriage and those involved in heterosexual relationships outside marriage marriage is a significant institution in indian society culturally there is a strong emphasis on marriage and it is seen as womens responsibility to make a successful marriage there were also accounts from women who were under a lot of pressure from the family to continue in an abusive marriage as leaving it would affect the family reputation participants from all three groups acknowledged the dominant stereotype that impact on women and their parental family this extension of damage to reputation is directed particularly to the mother of the bride as the community are likely to berate her for conflicts within marriage andor broken marriages this therefore functions as an additional layer of pressure to keep women in abusive or otherwise unsatisfactory relationships in addition life as a single woman in india is difficult i feel i can live a peaceful life only if i leave him but my mother and neighbours say that it is difficult to live without a husband in the case of women survivors who were brought up by a single parent they had been persuaded not to split away from their husband because their mother did not want the daughter to face the hardships of a single woman there was an implicit reference here to the ways in which community and society categorises women to be of loose character shameless and disrespectful when they break away from marriage and live as singletons in the context of women survivors who were in premarital sexual relationships they encountered a lot of pressure to marry the person with whom they were involved to justify their act of sexual involvement marriage is seen as legitimising sexual relations and offering protection against victimisation or illtreatment within the community being surrounded with this pressure participants insisted on marriage regardless of whether or not they loved the man they had had a sexual relationship with the cultural binding and different standards for sexual behaviour based on gender explains why women feel culturally bound to marry the person with whom they are sexually involved despite abuse torture and misuse and when they fail to marry this may lead to attempted suicide on the other hand mens reputations are not usually tarnished for their sexual relationships in comparison to women as indicated by the participants during the interviews a few of the healers in connection with relationships questioned why are girls held accountable for involving in a relationship or being seen with a man they questioned the social and cultural norms that discriminate between men and women and perpetuate double standards he has spoiled me i cant leave it at this i shall live or die with him alone i cannot marry anybody else and neither do i wish to participants discussed that it was important for women to be married by a certain age to avoid being stigmatised in the community unmarried women were particularly affected by stress and desperation when their family failed to find the right partner for her to marry as this was critical in avoiding stigma and could lead to suicidal behaviour it is implicit in the data that a woman gains her identity and status through a man in indian culture professionals and healers acknowledged the issue of stigma that forces women to suffer in silence and when faced with sufferings beyond their ability to cope result in attempted suicide a few of the male muslim healers were unsympathetic of women who were in premarital or extra marital relationships and they blamed women for their sexual involvement and problems in relationship while a woman professional also blamed women for conflicts in the family stating that women have reduced tolerance and coping abilities in modern days it brings to light how participants own religious and cultural backgrounds influenced the way they perceived risk factors and treated their clients among other reasons healers indicated that occurrence of suicide among women were high during menstruation they believed that women are more susceptible to the effects of bad omens during this period they were of the opinion that women are generally weaker than men which is the reason for the higher number of suicides among women than menbut this is contradicted by the evidence from suicide surveys the christian healers did not draw any relation between the higher rates of suicide among women and menstruation professionals discussed menstruation and suicide on the basis of hormonal changes indicating possibilities of depression and low moods there is a wide body of literature which discuss the association between suicide and menstruation from a biomedical perspective discussion the gender identity of men being men and women being women within the boundaries of cultural prescriptions laid a heavy burden of morality upon women survivors whilst at the same time men were reported to have the cultural power to regulate or deregulate female behaviour the social standards which attach morality to a womans conduct and behaviour are a result of cultural capital however these social standards for behaviour are questioned through the process of ongoing interactions between agency and social settingfield skeggs concept of frameworks of representations and values are appropriate in understanding a number of women survivors in this study these women materialised cultural capital power and practices which in turn produced structures within families and society to recognise a woman as a mother daughter professional wife and daughter inlaw with her own identity and set of values this was possible when a womans agency social cultural and economic capital interacted with family and social structures it is these frameworks that establish what it is to be a woman and not just a woman with cultural baggage as described by skeggs the evidence of social and cultural domination is exposed through the accounts of some of the healers who were under the influence of doxa they for example perceived women during menstruation as inauspicious affected by a bad omen emotional weak and prone to suicidal thoughts in this way healers were involved in what spivak calls ideological reproduction through the misreading of holy scriptures that legitimised their perception of women as sexually subaltern subjects inauspicious and prone to the effects of bad omens however some healers also recognised physical and emotional frailty during menstruation and its relevance to suicidal behaviour although healers perceptions were dominated by cultural and religious capital they recognised physical and mental health conditions from biomedical perspectives as well on the other side of the debate of womens identity are the women survivors experiences of premarital relationships physical and symbolic violence expressed in terms of fear resentment humiliation perceived and actual loss of power and being treated as an object of pleasure in this context women survivors attempted to persuade men to marry them with the aim of preserving honour cultural capital and reestablishing themselves within a social field however failure to achieve the desired outcome resulted in adopting a suicidal habitus attempted suicide in this case is used not only as a means of persuasion but as a measure to safeguard and politicise a womans identity and rights in order to influence her movement through social space the act of attempting suicide to politicise womens identity and rights is a way of demonstrating symbolic capital framing gender identity for men is interpreted in terms of masculinity through the symbolisms of cultural institutions and practices that define power authority independence and sexuality cultural representation of masculinity was an important aspect in the lives of male survivors they expressed distress about being unemployed having to wait upon parents for consent to marry lack of power and not being able to control their environment as a sign of diminishing social positioning which led to them perceiving themselves as being a loser failure and a loner butler recognises being a man and being a woman are internally unstable affairs they are set with ambivalence precisely because there is a cost in every identification the loss of some other set of identifications the forcible approximation of a norm one never chooses a norm that chooses us but which we occupy reverse resignify to the extent that the norm fails to determine us completely the enforcing nature of doxa cultural prescriptions for behaviours appearance and dressing based on gender was particularly distressing for a survivor who was transgender but also for other survivors society failed to empathise with the survivor and exercised symbolic violence by excluding him from respectable social positioning limiting opportunities for career advances and making it impossible to engage in a relationship this was distressing for the survivor who struggled to understand and accept the cultural norms and the harassment sanctioned by cultural power conclusion in conclusion this study has shown how crucial it is to recognise the role of cultural capital and power in understanding survivors experiences within the context of family and suicidal dispositions it further analyses the influence of cultural beliefs and doxaic norms upon service providers approaches to treating suicidal behaviour the study clarifies that it is not in identifying specific risk factors but in exploring the sociocultural process that affects social emotional physical and mental wellbeing that bears the potential to explain suicidal behaviours and plan appropriate interventions as a qualitative study the aims are not generalizability but transferability transferability refers to the ability of a studys findings to speak to and resonate with other similar contexts we do not claim that the transferability of this study would include those people who died by suicide

background this paper examines the social structures culture gendered roles and their implications for suicidal behaviour in south india exploring the cultural process within the structures of family and society to understand suicide and attempted suicide from the perspectives of survivors mental health professionals and traditional healers have not been achieved in the existing suicide related research studies conducted in india so far aims this study aimed to explore the cultural implications of attempted suicide by examining the survivors life stories their perceptions and service providers interpretations of problem situation methods a qualitative design was used drawing on constant comparison method and thematic analysis the analysis was underpinned by the theoretical concepts of bourdieus work indepth interviews were conducted with fifteen survivors of attempted suicide eight mental health professionals and eight traditional healers from southern india results the study found interactions among visible and invisible fields such as faith power control culture family religion and social systems to have strengthened the disparities in gender and role structures within families societies and impacted survivors dispositions to situations conclusions the role of culture in causing suicide and attempted suicide is explained by unravelling the negative impact of interacting cultural and structural mechanismsthe findings discussed in this manuscript is part of a larger study that explored the cultural and structural mechanisms of suicide in india the manuscript identifies a gap in perception and comprehension of risk factors which need to be positioned within the context of social and cultural process this has potential to inform prevention and intervention programs in india and worldwide

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introduction every outbreak of an epidemic or pandemic disease is accompanied by the tsunami of information which is also known as the infodemic infodemic makes it hard for people to find trustworthy sources and reliable guidance when they need it and causes social panic about health widens the gaps between races and regions and even brings the social chaos all over the world while most researchers and related parties made efforts to control the inaccurate information spreading online during the covid19 pandemic the infodemic influence caused by the overload of accurate information were almost or completely ignored and this will hinder the control of infodemic in future public health crises this study aims to explore the infodemic vs pandemic influence on peoples psychological anxiety across different media sources in the early stage of the covid19 outbreak in china methods a crosssectional study using online survey method was conducted by a datacollection service provider in april 2020 a total of 1117 valid samples were finally collected from 5203 randomly invited members via webpages and wechat the sample distribution covered the 30 provincial administrative divisions of mainland china results hierarchical regression analysis for the potential pandemic sources and infodemic sources of psychological anxiety showed that the infodemic factors of attention to the coronavirus information and commercial media exposure is positively related to the level of anxiety statistics indicated that influence of the infodemic factors is over and above that of the pandemic factors mediation analysis showed that information overload mediates the link between attention to coronavirus information and anxiety both information overload and media vicarious traumatization mediate the link between commercial media exposure and anxiety introduction background at the beginning of 2020 the whole world fell into an emergent public health crisis brought by the covid19 pandemic accompanied with the outbreak of the covid19 was the tsunami of the diseaserelated information which is known as the infodemic in this crisis media plays an important role in peoples information acquisition all media outlets were unprecedentedly active reaping countless high searching reading and forwarding volumes however some media outlets have also been criticized for providing false information inflammatory views and even unethical content although the pandemic has been under wellcontrol in some countries a series of social psychological and ethical issues brought about by the infodemic still worth to be reconsidered infodemic is a phenomenon described as an overabundance of informationsome accurate and some notthat makes it hard for people to find trustworthy sources and reliable guidance when they need it the world health organization declared that besides the pandemic threat originated by the covid19 virus an infodemic has been generated by a large amount of information available on the matter as well as by the difficulty to sort the veracious information from the false although the outbreak of sars in 2003 h1n1 in 2009 and mers in 2012 were all accompanied by rumors and false information creating different degrees of social panic the covid19 pandemic has developed unprecedented trend of infodemic with the emerging information technology which was defined as the first true socialmedia infodemic social media is considered a powerful tool for sharing health information related to pandemic risks after the covid19 outbreak 7080 of the chinese users reported an increase in the use of wechat infodemic including dissemination of conflicting or unclear messages misinformation rumors and conspiracy theories can profoundly cause public anxiety and social panic affect public health communication diminish preventive measures impede effective crisis management widen the gaps between races and regions and even bring the social chaos all over the world the heightened distress by the infodemic can also cause individuals irrational behaviors in the crisis such as health information avoidance spread of misinformation overuse of the healthcare services panic purchases incompliance with preventive measures the world health organization the united nations the united states centers for disease control and prevention and many other organizations had all engaged in fighting against the infodemic by debunking of false information stopping the spread of rumors providing the population with reliable data and updated news about covid19 technology industries including google amazon facebook youtube microsoft and twitter also implemented restrictions on publishing pandemicrelated content and removed medically disproved claims interesting enough existing studies seem suggest that online users have an adequate ehealth literacy and can effectively filter the false information in emergent public health crises studies showed that users can critically evaluate the source of the health information received and are capable to discriminate between reliable and unreliable content and they place higher trust in the medical professionals and scientists than the mass media and social media and they also rated the authorities social media channels as more trustworthy than the usergenerated content big data analysis also showed that information from questionable sources or false information posted on social media only represents a small fraction compared to the reliable or sciencebased ones researchers claimed that there is a higher potential of true information to capture more user engagement true information was also found to circulate more reach a higher level of diffusion spread more quickly and have a longer lifetime than false information these suggest that false information dissemination may not be the only cause of infodemic and public anxiety infodemic vs pandemic factors of public anxiety previous studies have shown that people generally have varying degrees of anxiety in the context of public health emergencies uncertainty situations make people more vulnerable to mental and psychological distress in the early stage of the covid19 outbreak especially in china people were exposed to unknown threats and highly uncertain about the infectivity susceptibility and treatment methods of the covid19 a study showed that more than half of the chinese participants suffered from psychological distress anxiety depression and stress at moderate to severe levels perceived risk of infection is one of the most direct factors that cause individual anxiety and fear studies have revealed that perceived risk of covid19 significantly associated with anxietyrelated feelings such as sleeping disorder stress worry and disruption of daily life besides the pandemic factors public anxiety levels are also largely influenced by the infodemic factors especially in the highly developed information technology era researchers found that the excessive social media use leads to increased levels of stress anxiety and vicarious trauma an online survey indicated a positive link between information exposure during the covid19 pandemic and the occurrence of anxiety and insomnia symptoms and the strength of the association increases with the duration of the media exposure major information sources of the covid19 pandemic not only involve social media but also traditional media experts and scholars criticized that social media as well as traditional mass media were disseminating inaccurate information during the covid19 pandemic and even most extreme pictures found elsewhere sending the wrong message were being used in many mainstream newspapers and tv reports information overload information overload represents a state in which an individuals efficiency in using information in their work is hampered by the amount of relevant and potentially useful information available to them the feeling of overload is usually associated with a loss of control over the situation and sometimes with feelings of being overwhelmed information is a doubleedged sword in the covid19 pandemic on the one hand effective communication of facts helps people to obtain adequate risk perceptions and make adaptive health behavior while on the other hand overloaded information can also impose strains on crisis management studies showed that as people are intensively exposed to negative information about a crisis their levels of anxiety and other unpleasant emotions could be triggered and elevated for an extended period especially when their personal experience with the disease is limited media vicarious traumatization vicarious trauma describes the trauma experiences people have after being exposed to others trauma stories and having witnessed the pain fear and terror that traumatized survivors have endured media could be another source of vicarious trauma when audiences indirectly experience the traumatic events via the vividly presented videos pictures and texts exposed by the media studies showed that obtaining more informational support via social media increased users vicarious trauma levels when the information and media content are perceived as threatening aversive emotions can be elicited and when information is contradictory or uncertain the distress may be even more elevated extensive research indicated that consuming media coverage to the natural or humanmade disasters typically associates with increased incidences of posttraumatic stress disorder anxiety and depression goal of this study most researchers and related organizations engaged in dealing with the control of false information dissemination online as well as their negative influence on public mental health and health related behaviors during the covid19 pandemic however a key question remained was that is the false information spreading the only cause of public anxiety a critical part was almost or completely ignored in the existing studies and countermeasures which is the infodemic caused by the overabundance of the mixed inaccurate and accurate information disseminated by the social media mass media and even government official media this study will focus on the influence of infodemic across different media sources on peoples anxiety in the early stage of the covid19 outbreak in china it aims to answer the following three research questions will the infodemic factors vs pandemic factors significantly associated with peoples anxiety what are the underlying mechanisms of the impact of infodemic on peoples anxiety that is how information overload and media vicarious traumatization mediate the impact what are the roles played by the three main information sources in the chinese media context in the infodemic methods recruitment the data were collected online by a sample service provider who owns one of the biggest online sample with more than 26 million members all over china the survey was conducted by randomly inviting 5203 members from the 30 provinces of mainland china via webpages and wechat in april 2020 a total of 1342 members responded to the invitation among them 225 invalid responses were systematically or manually eliminated by the sample service provider and the final valid responses received were 1117 with a response rate of 215 cities mostly influenced by the covid19 in the early stage of the outbreak were all covered and the regional distribution of the samples were as follows wuhan and other cities of hubei province guagnzhou and shenzhen of guangdong province wenzhou of zhejiang province beijing shanghai chongqing and other cities of the other 24 provinces participation of the survey was anonymous and voluntary ethical consideration the protocol of this study was approved by the institutional review board of shanghai jiao tong university the data were treated with confidentiality and the results did not identify the participants personally measurements psychological anxiety the psychological anxiety questionnaire was adapted from zungs selfrating anxiety scale participants were asked to rate their level of anxiety in the early stage of the covid19 outbreak on a 5point likert scale with three items including i feel nervous and anxious due to the coronavirus pandemic i have sleeping problems during the coronavirus pandemic and i feel panicky and cannot sit still easily during the coronavirus pandemic higher scores indicate higher levels of psychological anxiety cronbachs alpha of this questionnaire is 083 correlations between items 1 through 3 with the total score are 085 088 and 087 respectively pandemic factors participants were asked to rate their perceptions to the covid19 pandemic in the early stage of the outbreak four indicators were adopted from the widely used measurements for the health belief model variables perceived risk of oneself getting infected by coronavirus perceived risk of people around getting inflected by coronavirus worry about oneself getting infected by coronavirus and worry about people around getting infected by coronavirus infodemic factors participants were asked to rate their information consumption in the early stage of the covid19 outbreak which includes five indicators attention to coronavirus information and attention to information irrelevant to the coronavirus on 5point likert scales 1 hardly ever 2 less than an hour 3 13 h 4 35 h 5 more than 5 h exposure to different media sources including the government official media commercial media and social media on 5point likert scales information overload information overload was measured by the questions adapted from zhang and colleagues information overload questionnaire on a 5point likert scale including five items for example i find that only a small part of the coronavirus information is relevant to my needs i find that i am overwhelmed by the amount of coronavirus information i have to process on a daily basis and there is too much information so i find it a burden to handle cronbachs alpha of this questionnaire is 076 media vicarious traumatization media vicarious traumatization was measured by the questions adapted from the vrklevskis vicarious traumatization scale on a 5point likert scale with seven items including i was exposed to distressing news and experiences about coronavirus via media it is hard to stay positive and optimistic given some of the coronavirus information i get from the media and i find myself thinking about distressing coronavirus news on media cronbachs alpha of this questionnaire is 078 statistical analysis all statistical analysis were performed using spss statistics descriptive analysis concerning the minimums maximums means and standard deviations of the main variables were reported to examine the influences of the pandemic and infodemic factors on anxiety a hierarchical regression analysis was conducted including the control variables the pandemic factors and the infodemic factors in three blocks respectively improvements in model fit was indicated by the r 2 change in each block to analyze the underlying mechanisms of the influence of the infodemic factors mediational analyses using process macro model 4 were conducted direct and indirect effects were reported with their 95 confidence intervals results descriptives descriptives of the statistics are shown in table 2 psychological anxiety of the participants in the early stage of the pandemic is relatively low with the mean score of 283 out of 5 among the pandemic factors the average perceived risk of oneself getting infected is 4167 and the average perceived risk of people around getting infected is 4425 the mean score of worry about oneself getting infected is 349 and the mean score of worry about people around getting infected is 338 among the infodemic factors the mean score of attention to coronavirus information is 302 and the mean score of attention to coronavirusirrelevant information is 287 media sources exposed to the participants from the most frequent to the least frequent are social media government official media and commercial media the mean score of information overload is 297 the mean score of media vicarious traumatization is 327 regression analysis for the pandemic and infodemic factors of anxiety a hierarchical regression was conducted to analyze the pandemic and infodemic factors on psychological anxiety with the control variables entered to the first block the pandemic factors entered to the second block and the infodemic factors entered to the third block results showed that among the control variables age health condition and accommodation are significantly correlated to anxiety in specific participants who are older in poorer health condition or staying alone are more anxious than their counterparts gender and place of residence are not correlated to anxiety variance explained by the control variables is 0043 among the pandemic factors perceived risk of oneself getting infected and worry about oneself getting infected are positively correlated to anxiety after controlling for the effects of the control variables while perceived risk of people around and worry about people around getting infected are not significantly correlated to anxiety variance uniquely explained by the pandemic factors is 0062 among the infodemic factors attention to the coronavirus information and commercial media exposure are positively related to anxiety after controlling for the effects of the control variables and the pandemic factors while attention to coronavirusirrelevant information government official media exposure and social media exposure are not significantly related to anxiety the hierarchical regression analysis showed that variance uniquely explained by the infodemic factors is 0054 it also indicated a unique contribution of the infodemic factors on anxiety over and above that of the pandemic factors in other words statistics supports that the influence of the infodemic factors are beyond that of the pandemic factors in increasing psychological anxiety mediational analysis of information overload and media vicarious traumatization since the above analysis indicates that attention to coronavirus information and commercial media exposure are the two key infodemic factors the underlying mechanisms of these two factors was further explored with mediational analyses a mediational analysis was firstly conducted for the effect of attention to coronavirus information on anxiety results showed that when information overload is treated as the mediator the mediation effect is not significant and there is only a direct effect of attention of coronavirus information on anxiety when media vicarious traumatization is treated as the mediator the mediation effect is significant and the direct effect of attention of coronavirus information on anxiety is also significant that is the effect of attention to coronavirus information on anxiety is mediated by media vicarious traumatization a mediational analysis was secondly conducted for the effect of commercial media exposure on anxiety results showed that when information overload is treated as the mediator the mediation effect is significant and the direct effect of commercial media exposure on anxiety is also significant when media vicarious traumatization is treated as the mediator the mediation effect is significant and the direct effect of commercial media exposure on anxiety is also significant that is the effect of commercial media exposure on anxiety is mediated by both information overload and media vicarious traumatization discussion this study focuses on the infodemic vs pandemic influence on peoples anxiety across different media sources in the early stage of the covid19 outbreak among the chinese participants in specific it explored the influence of infodemic vs pandemic on peoples anxiety explored the mediation effect of information overload and media vicarious traumatization and compared the differences in the roles of government official media commercial media and social media findings showed that pandemic factors of perceived risk of oneself getting infected and worry about oneself getting infected are positively related to the level of anxiety infodemic factors of attention to coronavirus information and commercial media exposure are positively related to the level of anxiety government official media exposure social media exposure and attention to coronavirusirrelevant information were found to be the insignificant infodemic factors more importantly statistics also indicated that influence of the infodemic factors is beyond that of the pandemic factors mediation analysis testing the underlying mechanisms of the infodemic influence showed that vicarious traumatization mediates the effect of attention to coronavirus information on anxiety both information overload and media vicarious traumatization mediate the effect of commercial media exposure on anxiety the findings first suggest that the infodemic influence on peoples anxiety with mixed accurate and inaccurate information does exist which could possibly be more profound than that of the pandemic itself during an emergent public health crisis people are more inclined to acquire information in order to alleviate the sense of uncertainty however findings suggest that paying too much attention to the crisis information and being intensively exposed to certain types of media content about the crisis may exacerbate the anxious and stressful feelings findings of this study also indicated that even distractions from the coronavirusirrelevant information including entertainment games and daily news do not effectively alleviate the anxiety thus this further supports experts opinions that infodemic is not only caused by the spreading of false information or rumors accurate information routinely spread by different media outlets could also become potential sources of infodemic on the one hand it is important to increase the speed and width of spreading of information and scientific evidence from trustworthy sources such as the public health officials medical professionals scientists verified social media accounts official reports etc the most crucial and official information should be communicated by these credible groups in order to effectively lower the emotional taxing of the crisis on the other hand active citizenship against the spread of false information should also be advocated knowing that users have the potential to be trained to debunk false information through scientific literacy cultivation information overload and media vicarious traumatization were found to be the important underlying mechanisms explaining why and how infodemic may be associated with anxiety when individuals are intensively exposed to the crisis information it is inevitable to vicariously experience the traumatic contents which will in turn increase their level of anxiety this problem is more salient in the case of commercial media exposure compared to the government official media exposure and social media exposure commercial media may not only trigger the distressed perception by the overloaded amounts of reports but also bring about vicarious traumatization during the pandemic in china commercial media circulated vast amount of coronavirus information intensively and such information were further pushed to their users continuously with the utilization of artificial intelligence based on algorithms and historical data thus consumers of commercial media may passively receive overloaded coronavirus information that probably carries traumatic contents while researchers have proposed the empathic style of communication and personal experience sharing as the infodemic countermeasure our study suggested that such style could be inappropriate considering the vicarious traumatization effect of the media coverage on the contrary media should convey information to the public without sensationalizing the situation or providing disturbing images and videos so as to prevent bringing emotional trauma to the public comparisons across information sources showed that commercial media could be a major source of infodemic in the chinese media context commercial media coverages could directly and indirectly cause public anxiety by overloaded information output and vicarious traumatization such impact exists among the commercial media more obviously than other types of media and this could be explained by the marketoriented nature and the report genres of the commercial media commercial media in china intend to focus on those vivid cases from the microscopic perspective and their storytelling feature could more easily trigger the traumatic feelings of the audience in the early stage of the covid19 outbreak the commercial media were inclined to cover the contents such as the situation of the firstline treatment the patients and families stressful experience and how the wuhan citizens were expelled in other cities or countries meanwhile they tended to focus on the detailed and negative incisions from the patients family members and medical staff perspectives some typical examples include the article mother died in wuhan isolation ward released by phoenix news on 28 january 2020 the article wuhan community under the pressure of epidemic after the elderly died of high fever at home released by caixin on 29 january 2020 and the article when the hotel reception heard that i was from wuhan they immediately called the police released by thepaper on 28 january 2020 and these articles went viral in only a few hours in contrast the government official media coverages in china are more neutral macroscopic and sciencebased which mostly covered the authentic data progress of the pandemic and the government responses social media were usually found to be a major source of false information and rumors during crises in many studies however it is important to note that social media not only spread the crisis information but also play a role in the health information support as well as social and emotional support from family members friends and significant others this could be the reason why social media was not found to be a source of infodemic in the current study thus commercial media together with other media outlets should actively mitigate infodemic and public anxiety during public health crises by avoiding overloaded crisis information reports and detailed traumarelated content governments could also direct public health policies to address the impact of media portals in their routine spreading of information in times of pandemics rather than merely dealing with false information conclusion this study gives insights for the indepth understanding of the infodemic impact by analyzing the essential attributes of the infodemic from aspects of definition information sources communication mechanisms and social psychological impact the research findings provide valuable implications and suggestions for infodemic governance from the perspective of media practitioners policy makers and media consumers 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 shanghai jiao tong university the patientsparticipants provided their written informed consent to participate in this study conflict of interest the authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest publishers note all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations or those of the publisher the editors and the reviewers any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher

infodemic vs pandemic factors conclusion this study suggested that the influence of infodemic with mixed accurate and inaccurate information on public anxiety does exist which could possibly go beyond that of the pandemic information overload and vicarious traumatization explain how infodemic may be associated to public anxiety finally commercial media could be a major source of infodemic in the chinese media context implications for the related parties were discussed

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introduction global migration of healthcare workers is one of the most studied issues in healthcare worldwide driven by the global shortage of health care workers this move is considered a crisis in the human resources of the health sector 1 albania is characterized by a very high level of migration ranking it among the top countries in the world for the share and intensity of international migration 2 in total albania has approximately 23866 licensed nurses today according to the data obtained from the albanian order of nurses in year 2016 67 health care professionals left country and in 2017 131 health care professionals migrate and in 2018 211 health care professionals left country and in 2020 614 health care professionals left country and in 2021 1073 health care professionals left the country approximately 9 of nurses have left albania and this number is increasing constantly in the latest report published by the civil right center a nonprofit organization which refers to data gathered from the nurses order only for 2020 and 2021 a total of 1687 nurses and midwiferies have requested the certificate of good conduct from the nurses order this document is needed in order to apply to work as part of the health care system in other countries 3 the countries where the nurses and midwiferies graduated in albania prefer to practice are germany england usa canada etc germany is the largest migration market for health workers according to the federal government of germany 17 million people are employed in the nursing field and there are 40000 vacancies in health care institutions 4 on the official website of the german embassy in tirana we see that germany has a stable health care system however nursing professionals remain in demand and their contribution is more important than ever hospitals nursing homes and other health care facilities are always looking for nursing staff with various skills to meet the growing demand in the health care and nursing profes sions this demand is expected to increase in the upcoming years 5 the trend of emigration of health care workers seems to have affected not only albania but the entire region according to a report published by european training foundation albanian migration continues and is likely to do so into the future 8 the majority of member states of the world health organization report a shortage misdistribution and misutilisation of nurses 9 according to the who world health statistics 2022 report many countries continued to face shortages of health staff in key workplaces and struggled to achieve a balance in the distribution of health care workers… 10 this climate has stimulated the emigration of health workers to developed countries 11 according to the cgfns nurse migration report 2022 cgfns received over 17000 applications for 116 openings a 44 increase from 2021 and a 109 increase from 2018 12 cgfns international inc is an immigrationneutral nonprofit organization that helps foreigneducated health care professionals live and work in their chosen country by evaluating and validating their academic and professional credentials 13 according to predictions nursing workforce shortages are an issue of international concern with the gap between demand for services and limited supply of nurses widening countries impacted by nursing shortages have recruited internationally to fill vacancies with many countries now dependent on international nurses to meet domestic shortages 14 migration is predicted to continue until developed countries address the underlying causes of nurse shortages and until developing countries address conditions that cause nurses to leave 15 in the studies was found that international nurses from lowincome countries cited unfavorable working conditions and poor pay in their country of origin as but most impacted of all are the lowincome strata of society 16 according to a study conducted about the emigration of doctors in romania the factors that influence doctors decision to migrate are multiple they can be grouped into five motivational pillars economic context demographic factors remuneration policy political instability and working conditions 17 18 19 in general health care professionals from developing countries migrate to countries with strong health systems and more opportunities for advancement 20 objectives the purpose of the study was to explore the opinions of midwifery students studying at bachelor degree regarding their professional future and continuing education in order to understand the approaches and wishes of midwifery students regarding the choice of study and continuing education the following questions were raised 1 what do students think about the chosen profession 2 what are their professional expectations 3 nurse or midwife 4 what are the reasons why students were not registered to continue their studies at the masters level the research proposal was approved by the ethics council the students recruited in the study were informed about the study and its purpose the preservation of anonymity and were assured that the collected data will be used for study purposes only methodology and data analysis results results were presented based on a summary of demographic data and statistics found for each defined study objective what do students think about their preferred profession in response to the question related to career security as a midwife the majority of them refer that on average the career in this profession is secure and always secure followed by often secure and a not so secure and not at all secure our respondents in 50 of cases refer that the profession of midwife provides on average economic wellbeing and 104 think that the profession always provides economic wellbeing and that this profession often provides economic wellbeing 139 of them thinks a little and 07 not at all about 40 refer that the profession of midwife often belongs to a satisfactory social status followed by 333 an average of 194 always and 9 a little only 15 of the participants in our study affirm that they chose the midwifery branch because one of their family members or a relative works as a midwife and 85 say that this was not a deciding factor for them what are their professional expectations the students participating in our study in 62 of cases affirm that they chose the midwifery branch because they can immediately find a job regarding the choice of midwifery studies as it can provide you with a good career in the future 84 affirm and 16 deny this finding 80 of the respondents claim that they chose the midwifery branch because it can provide you with socialeconomic wellbeing while 20 deny that they chose this branch for such a reason nurse or midwife in response to the question whether the profession of midwife was recommended to you or was it a personal choice 243 refer that there was no recommendation at all 236 said that is was mentioned to them but was not a said that it was a factor in the overall decision over 60 of the participants in our study report that they are not at all ready to transfer their studies to nursing our respondents in 549 of cases do not agree at all that being a nurse is better than being a midwife the students were asked if they started the midwife program with the intentions of switching to the nursing program later on in their studies 70 said they did not plan on doing this while 30 said they did in a general perspective in terms of expectations for choosing the profession of midwife it turns out that students in over 60 of cases have chosen it themselves as a fild of study without being pushed by a family member or relative who practices the same profession and not because of the fact that creates opportunities for you to transfer to the nursing study compared to the nursing study program the students participating in our study do not think that they would transfer to this study program and do not think that this study program is better than the midwifery study program what are the reasons that students were not registered to continue their studies at the masters level the majority 90 affirm that they have chosen the midwifery branch because they can secure a job as a midwife in the countries of the european union while 10 reject this as a reason in response to the question of whether it is worth working as a midwife in albania 34 refer that it is worth it on average 333 it is worth it a little followed by 139 often 132 not at all and 56 always asked where they would like to work as a midwife and the three most desired countries are respectively germany 444 england 188 and italy 125 in response to the question if after completing the first level of study they plan to continue pursuing masters studies 80 of students refer that they will not continue and only 20 refer that they will continue their masters studies also in over 50 of cases they claim that they have chosen this field because they can immediately find a job and it provides you with a good career in the future and it offers you a socialeconomic wellbeing and the opportunity to find a job in a european union country the majority 90 affirm that they have chosen the midwifery field of study because they can secure a job as a midwife in the countries of the european union while 10 reject this as being a motivating factor among the individuals who have referred that they will not continue their masters studies in midwifery the main reason they will not continue in 696 of cases is the desire to leave albania followed by starting a job 157 this masters degree is unaccreditedunrecognized 78 masters degree is expensive 52 and will change profession 17 in a general look at the perception of the midwifery profession it results that discussion this study provided new insights into the thoughts and perceptions of students studying at the faculty of technical medical sciences in tirana albania given the reduced number of students who applied to study in the masters degree the purpose of the study was to explore the reasons and thoughts that led students to this decision in a general look at the perception of the midwifery profession in the study it turns out that students who follow the midwifery study program generally have a neutral opinion with a positive tendency about this profession they partly admit that the choice was personal and also recommended they consider it moderately difficult to find a job in this profession this profession can offer for them on average a secure career and economic wellbeing students are more optimistic about the satisfactory social and economic status worth it to work as a midwife in albania they admit that the choice was made freely and that they would recommend it as a profession to others the majority do not consider transferring to the nursing program of study and choose to stick to their choice but in the study it was discovered that most of them claim that they have chosen the midwifery study program since they can secure a job as a midwife in the countries of the european union their decision about the continuing the study seems to come as a result of their dissatisfaction with the salaries which according to the students do not provide them with enough income to afford living in albania likewise better working conditions hoped for in the chosen country are likely to increase their willingness to emigrate our findings also agree with previous studies in which it has been reported that workplace dissatisfaction is seen as a factor that stimulates emigration 21 it seems that this phenomenon has also affected the region in general because in a study conducted in kosovo 22 23 reported that dissatisfaction with wages and working conditions is strongly associated with migration preference among health workers 24 bidwell in this study reported that better working conditions are a decisive factor in keeping doctors in their countries of origin in the study it was observed that students do not have good expectations regarding their employment in the country of origin and this is one of the reasons that students do not prefer to continue their studies in albania in the study of the question asked where they would like to practice the profession of midwife it was noticed that a high percentage of students were very clear about the place where they would like to emigrate they preferred developed countries of the european union in the study it was observed that the three most desired countries are respectively germany england and italy the emigration of health care workers to these countries has been established for a long time and their employment offices have continual activities for outreach happening in albania 25 in our study it was observed that students affirmed that they wanted to continue their masters studies in their preferred field so the closure of the midwifery study program is not related to the current desire of students to pursue studies but to immigration security and accreditation of the diploma as a result of the enrolment of a small number of students the faculty chose to close the midwifery branch and merge the midwifery students with another program deviating the professional future of students and bringing into question the future of the program from the answers of the students it was found that most of them have chosen willingly the midwifery program because they can immediately find a job as midwife they also think that emigrating to a european union country will ensure a better career in the future and socialeconomic wellbeing although midwives agreed to study nursing they do not at all agree that being a nurse is better than being a midwife and the majority of respondents in the study report that they are not at all ready to transfer their studies to nursing this explains that they had preferred midwifery but the current conditions forced them to accept the option offered by the faculty the large number of respondents admitted that the choice coincided with the possibility of employment and also brought to light another fact that the expectations of students regarding this program were high when they started their studies but they decreased during further years of study this coincides with the fact that over the years they have had the opportunity to get to know the profession and it has been possible to contact professionals in the field the trend of mass movement of health care workers is very sensitive in albania as well the mass exodus of health care workers even though the number of graduates meets the countrys needs today will affect the future the trend of mass movement of health care workers is very sensitive in albania as well the mass exodus of health care workers even though the number of graduates meets the countrys needs today will affect the future our study highlights that if government policies would pay more attention to the dignified treatment of health care workers including increased wages and improved working conditions mass emigration could be controlled without affecting quality and the countrys health care staffing needs despite the desire of students to emigrate and the growing trend of nurses and midwives leaving albania a study has not yet been conducted regarding the professionals who left today with the desire to return later it seems that the governments promise to increase the salaries of health workers has not had any effect on reducing the number of workers who want to leave the country conclusions as market demand for nurses around the globe escalates the changes and consequences associated with nurse migration increasingly need policy solutions that reflect the needs and motivations of all actors our study highlights that if government policies paid more attention to the dignified treatment of health care workers including increased wages and improving working conditions the mass exodus of workers could be controlled without affecting quality and the countrys health care staffing needs the reasons for emigration are not just a simple desire for more incomes but health care workers require much more than that today employee satisfaction includes not just better salaries but also the satisfaction of working in a place with suitable working conditions opportunities for the future accredited education and much more safety and security lead to further life issues accomplishment and this is a clear desire among health care professionals in albania conflicts of interest the authors declare no conflicts of interest regarding the publication of this paper

introduction international migration has always existed primarily as a means to find economic opportunity recently the number of health care professionals seeking to work outside albania is growing rapidly in 2021 alone 1073 nurses left albania the departure of health care professionals is reflected in education where it can be observed that a good part of the students who finished the bachelors level program did not enroll to continue the second level of study in the masters the students decision not to continue further levels of education has brought consequences from programs shutting down due to lack of students and forcing the university to spread out the few remaining students to other programs objective the purpose of the study was to explore the opinions of midwifery students studying at the bachelor level regarding their professional future and continuing education methodology this is a crosssectional study in this study are included the students of the bachelor level of education student participating are studying midwifery in the 20222023 academic year at the faculty of technical medical sciences at the university of medicine albania results the students on average believe they can find a job as a midwife the career is relatively safe and the profession of midwifery will ensure economic wellbeing for them most of the students hope to emigrate and develop their professional career outside of albania this was a surprise given that most frequent answers given by the students for not continuing their masters level education was the fact that the program was not accredited their bachelors diploma was also not accredited and so not recognized by other countries the cost of continuing their studies was too high and their desire for a better economic and social status which they cannot get in albania the majority of students participating in the study identified emigration as the main way they plan to further their studies conclusions and recommendations although the students

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background alcohol use is among the leading causes of morbidity and mortality for emerging adults age 18 to 24 years 1 approximately 54 of college students and 50 of their noncollege attending peers report alcohol use in the past 30 days 2 a particularly risky setting for alcohol consumption and associated negative consequences are alcoholthemed events and parties such as new years eve st patricks day spring break or halloween 34 these events can lead to heavy episodic drinking even among students who typically abstain 35 previous work has illustrated associations between heavy alcohol at these events and negative health and behavioral consequences including driving after drinking and committing acts of theft or vandalism 6 one specific alcoholthemed event takes place yearly in madison wisconsin the mifflin street block party held in may on a major street adjacent to the university of wisconsinmadison campus is a daylong event in which 2 blocks of mifflin street are blockedoff from vehicular traffic and booths are set up with music and food in 2011 alcohol was served to those who are over age 21 the street and nearby offcampus student housing become a destination for partying by approximately 1000015000 individuals a majority of msbp attendees are students though other members of the madison community attend as well in recent years the msbp event has led to arrests for open containers and underage consumption 78 as well as more serious violent offenses 9 alcoholthemed events like msbp occur at many colleges and universities and can present challenges for institutions wishing to keep their students safe from alcoholrelated harm 3 as law enforcement communities and universities consider novel approaches to appropriately limit or sanction alcoholthemes events innovative ideas to reduce harm are needed use of online social networking sites is widespread among emerging adults and may offer new possibilities for identification of problem drinking and interventions to prevent related consequences during alcoholthemed events nearly 75 of 1824 yearolds use facebook 10 and 31 use twitter 11 the two most popular snss young adults with dense online social networks and strong emotional links to their online peers report more alcohol use 12 online discussions of substance use have been found to support social norms that are permissive of alcohol use 13 research among college students demonstrates that they frequently display references to alcohol consumption on their facebook profiles 1415 these references are positively associated with clinical measures of problem drinking 16 a 2014 study in the wisconsin medical journal illustrated that uwmadison students frequently posted on facebook about their intention to attend the msbp and these postings were highly correlated with high levels of alcohol consumption at msbp 17 nearly half of emerging adults own a smartphone that permits mobile use of snss 18 a majority of facebook users in the united states access the site via a mobile device 19 but previous research has not addressed whether social media is used during episodes of drinking when there are other sources of influence competing in real time for attention from a public health perspective the use of snss from mobile devices creates the potential to reach individuals where and when they are actively drinking alcohol prior qualitative work suggests that some college students thought sns features could be useful for obtaining help in an emergency or if safe transportation is needed 20 but the extent to which emerging adults use snss in real time during alcohol consumption remains unknown understanding the characteristics of those who may use sns in this manner could have implications for targeting efforts to prevent alcohol related harm female gender is associated with higher use of snss generally 21 but it is unclear if this holds true in the context of alcohol use further those who engage in heavy episodic drinking are at high risk for alcohol related problems so it is useful to understand whether that type of drinker is also using snss thus the purpose of this exploratory study was to 1 assess the proportion of emerging adults who use facebook andor twitter during a drinking event 2 determine whether use of these snss varies by gender or drinking intensity and 3 assess patterns in intent to use snss for planning transportation methods study design this crosssectional study utilized participant interviews onsite at a large alcoholthemed event to capture realtime data setting data were collected during the mifflin street block party in may 2012 this event had approximately 5000 attendees most of whom were college students this event was an ideal environment in which to study drinking behavior and sns use in realtime as it had a significant social media presence with 7959 likes on the events facebook page as of november 1 2012 22 study procedures were approved by the institutional review board at the university of wisconsinmadison procedure during the street festival between 12 pm and 5 pm 7 research assistants were present at the msbp in 5 different locations the research assistants were trained to use a standardized protocol for data collection the data collectors selected and approached individuals and asked if they were interested in participating in a brief interview about social media and alcohol use after a script was read interested individuals provided oral consent data collectors read interview questions to the participants and recorded their responses using pen and paper the interview lasted approximately 510 min data collection rather than asking participant age directly age was assessed as a yesno response to the question are you between the ages of 18 and 23 in order to avoid disclosures of underage drinking the interviewer then assessed gender to assess alcohol consumption the interviewer asked the participant if heshe had been drinking any alcohol that day participants who indicated they had been drinking were asked what time did you begin drinking today and how many drinks have you had so far the interviewers recorded the time the interview took place so that the duration of drinking could be calculated all participants who indicated that they had been drinking were asked about sns use to assess sns use drinkers were asked have you used facebook since you started drinking today and have you used twitter since you started drinking today finally to assess patterns in whether sns are used for planning safe transportation we asked all participants do you plan to use facebook or twitter to arrange transportation home tonight participants received a small bottle of water as an incentive for participation constructed variables drinking duration was calculated by subtracting the reported time that drinking began from the time at which the interview was conducted the rate of drinking was obtained by dividing the number of reported drinks by the duration of drinking we multiplied the hourly rate by 2 in order to obtain an estimate of heavy episodic drinking that was in line with g criteria from the national institutes of alcoholism and alcohol abuse defining heavy episodic drinkers as males who drank at a rate of 5 or more drinks in two hours and females who drank at a rate of more than 4 drinks in 2 h 23 we categorized heavy episodic drinkers as those with a drinking duration of 2 or more hours and a rate greater than or equal to 5 or 4 drinks per 2 h analysis all analyses were conducted using stata 12 computer software analysis first involved calculating descriptive statistics for all variables chisquare tests were used to assess differences in categorical variables by gender and status as a heavy episodic drinker fishers exact test was used in instances where the expected values were less than 5 observations in at least one cell of the 2 × 2 table ttests were used to assess betweengroup differences for the continuous variables for drinking duration and number of drinks results a total of 200 individuals completed the study and 52 were male research assistants approached 214 individuals 8 people refused to participate and 6 were ineligible due to being outside the target age range of 18 to 23 years the majority of emerging adults surveyed reported drinking alcohol on the day of the event on average participants had been drinking for 5 h and consumed 74 drinks almost one quarter of participants had met niaaa criteria for heavy episodic drinking males and females had statistically significant differences in the number of drinks consumed at the event and in the duration of drinking with males having higher values on both of these measures the proportion of participants who met criteria for heavy episodic drinking was similar for males and females chisquared tests indicated this difference was not statistically significant overall 32 of participants used either facebook or twitter since they began drinking that day with 23 reporting facebook use and 18 reporting twitter use use of both snss was higher for females than for males for females 42 used either sns at the event whereas this was true for only 25 of males there were several differences in sns use based on the intensity of drinking as shown in table 3 more heavy episodic drinkers used facebook compared to nonheavy episodic drinkers twitter use was less common among heavy episodic drinkers than among nonheavy episodic drinkers although this difference was not a statistically significant difference use of sns for transportation planning was relatively rare for the sample overall but heavy episodic drinkers were more likely report intention to use sns to plan transportation compared to nonheavy episodic drinkers discussion and conclusions to our knowledge this is the first study to investigate the use of social media during a public event at which alcohol consumption is a primary activity it builds upon prior knowledge demonstrating that the use of mobile devices and social media are ubiquitous among the emerging adult population 24 by assessing the proportion that use social media while they are actively drinking the purpose of this study was to assess whether emerging adults use social media during the day of a drinking event as understanding this could provide a basis for considering in this study heavy episodic drinkers known from previous work to be at elevated risk of alcoholrelated motor vehicle crashes used facebook during the drinking episode at higher rates than nonheavy episodic drinkers and used twitter at lower rates this is consistent with previous studies which showed positive associations between displaying alcohol references on facebook and selfreported problematic alcohol use 16 this study extends those findings to illustrate that in some cases the displayed alcohol references are happening in realtime during a drinking experience use of social media use for transportation planning during this event was relatively low this may be because many individuals walk to the event and therefore do not spend much time considering transportation or it may reflect the idea that other forms of communication are used to plan transportation rather than social media this is an area that warrants future exploration it is possible that if safe ride services were advertised and offered via social media sns use to plan transportation would increase heavy episodic drinkers also had a greater tendency to indicate intent to use sns to plan transportation resources to facilitate use of safe transportation especially delivered through the facebook environment may be able to reach a population of highrisk drinkers one practical translation of this finding could be to encourage event organizers to disseminate messages about a free shuttle bus service or taxi stand locations to individuals who like the facebook page of the alcoholdrinking event this tactic could allow prevention efforts to be directly and inexpensively targeted to a highrisk population mobile users of facebook like those in this study would receive these messages and could potentially even be able to interact with the organizers via facebook during the event future studies could explore the feasibility acceptability and outcomes of such an this study has limitations the potential for selection bias exists because we did not apply standardized random sampling techniques though we endeavored to sample a variety of event attendees by conducting data collection throughout the duration of the festival and at different locations within the event the data was selfreported and therefore potentially subject to recall bias there is also the possibility of social desirability bias though prior research indicates that young adults disclose heavy episodic drinking behaviors in other inperson assessments 2526 the data collectors were young adults themselves which may have helped minimize the potential for this bias it is possible that being under the influence of alcohol could have led participants to over or underreport their alcohol consumption which is a limitation of any study in which participants have consumed alcohol our method for classifying heavy episodic drinkers may have underestimated the number who engaged in this behavior at some point during the day of msbp because the sample was drawn from one event on one day the results may not be generalizable outside the context where the study occurred efforts to examine whether these results hold true in other settings are encouraged in conclusion nearly onethird of emerging adults used snss while drinking on the day of msbp an alcoholthemed event those who drank heavily were more likely to use facebook compared to those who did not drink heavily this finding should motivate universities and event organizers to incorporate social media especially facebook into their plans for advertising harm reduction strategies and offering safe ride services when alcoholthemed events take place additional research will be needed to evaluate the reach and impact of such efforts nonetheless this study is an important first step towards understanding the potential for targeted realtime interventions that use social media to influence behavior related to risky alcohol consumption and alcohol impaired driving competing interests the authors declare that they have no competing interests authors contributions jw performed the statistical analysis and drafted the manuscript mp participated in the design of the study coordination and data collection and helped draft the methods of the study in the manuscript mm conceived of the study and participated in the design and coordination and helped to draft the manuscript all authors read and approved the final manuscript

background emerging adults have high rates of heavy episodic drinking binge drinking and related risks including alcoholimpaired driving to understand whether social networking sites snss used on mobile devices represent a viable platform for realtime interventions this study measured emerging adults use of two popular snss facebook and twitter during the mifflin street block party this annual festival is held in madison wisconsin and is known for high alcohol consumption findings event attendees ages 1823 years were recruited by young adult research assistants 21 years participants completed a brief inperson interview assessing drinking intensity use of snss and use of snss to plan transportation analyses included ttests chisquared tests and fishers exact tests at the event nearly all of the 200 participants 97 consumed alcohol and 18 met criteria for heavy episodic drinking approximately onethird of participants had used facebook or twitter on the day of the event facebook use 23 was more prevalent than twitter use 18 especially among heavy episodic drinkers use of either sns was 41 among females and 24 among males χ 2 601 df 1 p 001 plans to use a sns to arrange transportation were relatively uncommon 4 but this was more frequent among heavy episodic drinkers 11 compared to nonheavy episodic drinkers 2 fishers exact p 002 conclusions these results indicate that snss are used during alcohol consumption and warrant exploration as a way to facilitate connections to resources like safe ride services

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introduction although efforts to integrate checklists for assessing bias in educational content represent a sincere effort to address or mitigate harm such efforts will likely have limited impact on curricular reform or the actual lived experiences of racially and ethnically minoritized students at best they signal an important shift among educators toward critical reflection on deeply held beliefs that are transmitted to students through curricular content in ways that eventually impact patient care and also reflect a growing awareness that medicine harbors social injustice in its treatment of race ethnicity gender and other characteristics 1 however the integration of antibias checklists into curricula is of limited value in that such checklists can only serve as a first and primarily superficial line of defense for identifying overt instances of stereotyping bias shaming and stigma 2 what is required to transform health professions education is a far more substantial reenvisioning of both pedagogies and curricula and linking them to a justiceoriented system of assessment and evaluation 3 john rawls argues that social and economic institutions should be to the greatest benefit of the least advantaged members of society 4 using this difference principle we argue that current approaches to curriculum development and assessment including the widespread integration of antibias checklists to ensure inclusivity and fairness ultimately fail to account for the ways in which power privilege and oppression manifest in our curricular and pedagogical assumptions and as such continue to benefit those individuals who have historically dominated health professions education ultimately by merely identifying harmful images or language in curricular materials health professions education treats injustices as incidental rather than structural a justiceoriented approach in place of checklists we propose a justiceoriented approach to curricular reform and assessment which centers the needs of marginalized populations in all educational decision making whereas checklist questions may ask does my curriculum contain an adequate number of images of racially diverse individuals or is the language to describe race in my curricula problematic a justiceoriented approach would prompt educators to ask this central question how are my assumptions about marginalized populations being forwarded in my curricular and assessment materials and how can i actively disrupt these assumptions to center lived experiences of other populations this line of questioning is qualitatively different from what is typically included in antibias checklists because checklist questions do not challenge the hegemonic structures and symbols that keep injustice and inequity in place curricular choices have to be more than not racist they must be explicitly and irrefutably antiracist in other words avoiding the portrayal of negative stereotypes of minoritized populations does not seek to disrupt stereotypes instead we need to attend to the ways in which whiteness is embedded in our educational and training systems whiteness in health professions education whiteness is the hidden structure that organizes our institutions providing advantages to those already in positions of power 5 in health professions education it functions at the level of social norms influencing the ways physicians think act and feel in their professional roles as well as the expectations that health professions schools place on them 6 to give an example of how whiteness might be left untouched by antibias checklists olsen 7 found that medical educators routinely offload their instruction on issues of race onto health professions students particularly those who are racially minoritized she showed that educators encouraged students to share their racial experiences in smallgroup settings but used race as a biological model in the didactic portion of the course this pedagogical choice thus reinforces the dominant narrative that race is biological and exposes students to unnecessary racial mistreatment from their peers an antibias checklist would likely have captured the racial bias in the didactic portion of the course but not in the informal unstructured smallgroup interactions from a justiceorientedantiracist approach its obvious that whiteness was present in faculty members pedagogical choice to organize their course in the manner that was chosen although faculty members acknowledged that racially minoritized groups have different social realities evidenced in creating space for these discussions the formal curriculum treated race as a biological reality a harmful framing that has been used throughout history to justify the mistreatment of black and brown individuals 8 by sidelining class discussions of race and then highlighting race as a biological reality faculty members privileged the dominant perspective on race without actually encouraging students to decenter white privilege other examples in which white privilege may be left untouched by antibias checklists include inappropriate use of racially coded language in trainees performance evaluations 1 an aspect of the curriculum that is not covered by checklists interactions are a crucial component of the learning process in that they shape how physicians think about the work they do the populations they serve and their role in the process of care given that historically medicine has been largely a white profession 9 whiteness is embedded throughout all aspects of medical training and practice even though it goes unrecognized 10 antibias checklists allow whiteness to maintain a preferred status within curricula and assessments 11 leaving few or no opportunities for faculty to interrogate why whiteness is used as an organizing framework in medicine in the first place refocus on critical consciousness to create real change in health professions education the profession needs a collective shift toward increased critical consciousness 12 critical consciousness equips individuals to question how power and privilege are maintained in society with the end goal of achieving liberation 13 facilitating this shift will require our profession not only to develop curricular checklists but also to invest in the consciousness raising of educators and assessment developers to disrupt the hegemony of whiteness rogers and mosley 14 remind us that multiple aspects of society work in concert to construct and represent whiteness as normalized and privileged and this normalization is what makes the logic of whiteness difficult to recognize and thereby permits its continued perpetuation what is needed are ongoing consistent and perhaps uncomfortable conversations aimed at raising faculty members critical consciousness for instance faculty members need opportunities to question why stereotypes have been used as heuristics in teaching disease processes to discuss how assessment systems uphold the current social order that disadvantages minoritized groups and to challenge the heteronormative white perspective that is embedded throughout health professions education additionally they need opportunities to discuss more mundane issues such as the fact that checklists are human artifacts developed in a specific temporal context and as such represent the communitys thinking at a specific moment in time for example while racism and sexism may be well represented in current checklists there are other forms of bias that have not received the same amount of attention such as ageism which is a relatively new form of bias and has only been recently identified because the pedagogical approach used by most health professions schools is heavily biased against the management of older patients 15 similarly stereotypes which are subject to societys changing understanding of what constitutes a specific identity are not represented in antibias checklists 16 in essence faculty members will need to understand that constructs are not static they shift incrementally and are shaped by society 17 these kinds of conversations can help to disrupt fossilized understandings of social reality and reframe constructs as dynamic and responsive to societys changing values beliefs and influence although professional development is often encouraged alongside antibias checklists 2 we believe professional development with the end goal of raising critical consciousness with respect to issues of whiteness should be the focal point in creating a justiceorientedantiracist approach to both curriculum development and assessment until the focus shifts from superficial concerns such as representation to a contextual presentation of material about race disability gender and so on the deepseated change that is needed in our profession will never be realized a key goal should be to understand how whiteness has shaped health careespecially medicinein ways that have until this moment gone unrecognized conclusion ultimately if health care is to center justice it needs to work towards a collective elevation of its critical consciousness 18 with more deliberate attention to the ways in which current and historical power structures are deeply embedded in curricular and assessment design by focusing on how the health professions perpetuate sociopolitical injustices and designing assessments that ensure that this understanding stays elevated the profession can resist a reductionist approach to addressing harm and injustice and begin to transform health professions education we propose a justiceoriented system that involves a deep interrogation of both curricular content and pedagogies to show the ways in which power privilege and oppression manifest in assumptions underlying assessment and teaching practices 11 conflict of interest disclosure authors disclosed no conflicts of interest views expressed herein are those of the authors and do not necessarily express united states federal government policy the viewpoints expressed in this article are those of the author and do not necessarily reflect the views and policies of the ama copyright 2024 american medical association all rights reserved issn 23766980

this article argues that although efforts to integrate checklists for assessing bias in educational content represent a sincere effort to address or mitigate harm such efforts will likely have limited if any impact on curricular reform or the actual lived experiences of minoritized students this is because checklists are not designed for justiceoriented assessment and thus will not create the kind of change needed to transform health professions especially medical education what is needed is more attention to the ways whiteness is used to organize health professions education and a deep commitment to faculty development focused on raising educators critical consciousness

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background and introduction prior to the covid19 pandemic the level of wellbeing among students had already been a big concern as we observed a high prevalence of youth risk behaviors such as unhealthy eating physical inactivity substance misuse and emotional disturbance in many countries both east and west 1 2 3 4 5 studies have shown that adolescents now have a higher exposure to health risks than those in the past therefore adolescent health should be given higher priority in public health policies based on a systematic analysis of data reflecting the global health burden of adolescent heath 67 and the worldwide application of prevention science in adolescent health applications 8 accordingly the 45th session of the un commission on population and development chose adolescents and youth as its central theme 9 since then the covid19 outbreak has had a further significant impact on the mental health education and daily routine of students changes in daily routines including a lack of outdoor activity disturbed sleep patterns and social distancing have affected the mental wellbeing of students 10 it has been observed that the decline in the level of physical activity and the prolonged use of electronic media have increasing effects on students learning concentration and sleep patterns 11 studies have also found an increasing prevalence of obesity 1213 and myopia 14 among school children due to longer screen times a lack of physical activity and small crowded living and learning spaces a study on tertiary students found that over 60 experienced increased stress and around 30 experienced moderatetosevere levels of depressive symptoms with the increasing use of electronic devices and decreased participation in outside activities was positively associated with a higher level of depression severity 15 another study reported that 9 of students had depression and 14 had anxiety and 254 stated that their mental health had deteriorated since the pandemic 16 the health of adolescents has been further compromised by the covid19 pandemic nine potentially protective aspects of youth and family behavior occurring during the prior month including physical activity time spent in nature and outdoors appropriate screen time and sleep quantity have been identified in a longitudinal study to dampen the negative impacts caused by covid19 on adolescents wellbeing 17 adolescent health should place emphasis on the enhancement of the aforementioned protective factors and minimize risk factors nonetheless the question remaining was how should the services be delivered effectively to meet the needs of adolescents to reach the penultimate goal of health improvement for the effective delivery of health services to children and adolescents their voices should be heard but unfortunately due to the circumstances of being a minor they are usually only represented by adults who may not necessarily reflect their best interests and real needs 18 evidence has highlighted the importance of including youth experience and voices in the planning delivery and evaluation of services 19 in many countries school health services play an active role in preventive care in the form of screening preventive services and health promotion particularly regarding mental health 20 the participatory approach involves children and adolescents and focuses on the conditions necessary to reduce risk factors and collaborative services in primary health care can help to determine the needs of children and adolescents 20 an assessment of their needs is required to reflect their best interests and an analysis of their level of health risk behaviors is more relevant than morbidity and mortality data adolescents do not usually perceive their risks of developing chronic conditions as they happen years later so they should be provided with data reflecting their immediate risks health communication targeting risk perceptions can lead to behavior change 21 studies have shown that interventions successfully changing risk perceptions often result in behavioral change 2223 disease risk perception is a critical determinant of health behavior 24 adolescents risk perception can only be enhanced if they know the existence of the risks and this may motivate them to expose themselves to protective factors studies are needed to investigate youth health behaviors during the covid19 pandemic in order to enable adolescents to perceive their risks and service providers need to reorientate their service provision in order to cultivate a supportive environment conducive to healthy living and to mitigate the negative repercussions caused by the covid19 pandemic with the maximum participation of adolescents youth service providers need to work upstream and address the determinants of health rather than downstream with the provision of routine services this study aims to provide a general overview of secondary school students health profiles including health risk behaviors lifestyle and health status and healthseeking behaviors including the utilization of student health services during the covid19 pandemic the findings of this study may fill the gaps in youth health needs assessments as routine clinical data do not capture the data required to cultivate a better living environment for adolescents in the postcovid19 era which is more important to protect and promote the health of adolescents and early identify potential risk factors materials and method study design this is a crosssectional study and it was carried out with the use of an electronic questionnaire to determine secondary school students school health profiles including health risk behaviors lifestyle factors health status and the utilization of student health services this study further analyzed the associations between health status and health risk behaviors lifestyles and shs utilization the study was approved by the survey and behavioural research ethics committee of the chinese university of hong kong the survey was conducted anonymously the participating schools obtained consent from parents and students and students participation was entirely voluntarily with no adverse repercussions study population the study population was secondary school students district one of the 18 districts in hong kong which has a district population of around 560000 it was chosen because the district is a pioneer in the healthy city project 25 and it has established a framework for a medicalsocialcommunity model 26 however the median monthly income in k t is among the lowest in hong kong in 2019 the k t district became the first district to establish a district health centre which is part of a key government policy implemented to strengthen primary healthcare with the provision of nursing and allied health services including social workers and to support primary medical care providers in the district the findings of this study may reflect the health needs of adolescents living in low socioeconomic conditions and investigate how the community health initiatives help to meet those health needs sample population based on previous studies the prevalence of students with emotional disturbance is around 25 3 and for students performing regular exercise the prevalence is also around 25 4 a sample size of 288 is needed for a margin of error of 5 e 2 z 196 with a significance level at 5 p 025 and for population proportion and e 005 the margin of error 196 2 × 05 × 0501 2 288 assuming π 0 the null hypothesis proportion is 025 the prevalence of certain health behaviors and health conditions is 25 for one group of students and π 035 for a higher proportion among another group of students the sample will be 125 per group giving a power of 80 of significance at 5 v 196 2 086 × 046 196 × 05 015 × 015 125 therefore a sample of over 300 students was needed the k t district is broadly divided into two main subdistricts kwai ching and tsing yi according to the 2016 population bycensus the total population and adolescent population are 336405 and 32355 in kwai ching respectively and 184167 and 12579 in tsing yi respectively stratified cluster sampling was adopted to randomly select three secondary schools and two secondary schools from kwan chung and tsing yi respectively in order to reflect the proportion of the population of the two subdistricts from each school students from secondary 2 aged around 1314 and students from secondary 5 aged around 1718 were selected for this study to represent early and late adolescents s1 students were new to the school and s6 students were busy with public examinations so s2 and s5 students were more appropriate study subjects study tools this study utilized the hong kong student health survey questionnaire to measure health risk behaviors lifestyle factors and health status hkshq is used by the centre for health education and health promotion of the chinese university of hong kong as a system of surveillance of student health status 27 and it is continuously refined as a tool for the assessment of student health statushealthrelated outcomes 11 in a previous study the tool was able to reveal that a decline in the level of physical activity and the prolonged use of electronic media had increasing effects on students learning concentration and sleep patterns 11 questions were added to report the utilization pattern of shss questions screening for posttraumatic stress disorder were included as the covid19 pandemic has had serious repercussions on mental health 16 before the outbreak of covid19 there was an intense social movement in 2019 and during the heights of the movement in late 2019 a public mental health crisis was generated resulting in a prevalence of 112 for depression and 128 for probable posttraumatic stress disorder 28 ptsd can be easily overlooked as individuals may present with vague complaints with little or no account of the trauma that they experienced and emotional numbing if ptsd is suspected a few key screening questions may be useful to avoid problems in diagnosis so this study adopted four key screening questions to alert professionals to the possibility of ptsd which may require referral for further evaluation 29 data collection letters of invitation were sent out to the schools sampled in march 2021 and they contained information about the study a sample questionnaire and a consent reply form the schools were then provided a link so that students could access the electronic questionnaire and complete the questions data analysis descriptive data of all variables derived from the questionnaire were computed as categorical variables data analysis was performed using spss statistics software the proportions of particular outcomes were tabulated certain categorical variables were converted into binary variables the mode of sleep time duration reported by students was 6 h so it was used as a dividing line regarding exercise for substantial health benefits in adults the centre for health protection of hong kong special administrative region recommends engaging in at least 150300 min of moderateintensity aerobic physical activity at least 75150 min of vigorousintensity aerobic physical activity or an equivalent combination of moderateand vigorousintensity activity throughout the week 30 therefore more than 60 min of moderatetovigorous intensity activity 3 days per week was used as a dividing line chp recommends 5 servings of fruit and vegetables 30 and the mode of fruit and vegetable intake reported in this study was a 05 serving so 1 serving was used as a dividing line for symptoms of ptsd those with two symptoms were classified as positive to allow for a higher level of alertness 29 for screen time 2 h was chosen as a dividing line as the american academy of pediatrics advises no more than 12 h of screen time for children 31 the chisquare test was used to analyze differences among dichotomous dependent variables at a 5 level of significance multiple logistic regression was utilized to identify the independent variables associated with emotional distress results a total of 585 students comprising 120 and 159 male students and 134 and 172 females students from s2 and s5 respectively participated in this study of five secondary schools randomly selected using stratified cluster sampling as described in the section 2 table 1 shows the prevalence of different living habits lifestyles health status and the utilization of student health services around 30 of students slept less than 6 h per day with poor quality nearly half spent over 2 h watching television playing electronic games and using social media platforms most students had a very poor consumption of fruits and vegetables with one serving or less and a low level of regular exercise over 20 of students felt emotional distress that affected their daily activities and over 40 felt the need to seek help nearly 20 of students had symptoms suggestive of ptsd however nearly 80 of students did not attend student health services regularly the prevalence of selfreporting substance misuse was found to be very low at 02 figure 1 shows the reasons for sleep disturbance the four main reasons reported are failing to fall asleep within 30 min nightmares waking up in the middle of the night or early morning and a hot environment there is a significant association between sleep quality and sleeping hours with 779 of students sleeping 6 h or more and only 485 of those sleeping less than 6 h rating their sleep quality as being good there is also a significant association between sleeping hours and time spent on social media with 785 of students sleeping 6 h or more and only 631 of those spending less than 2 h on social media we observed a high proportion of students spending a lot of time using screens and reporting emotional disturbance as can be seen in table 1 this may be related to sleeping hours and quality of sleep the students level of exercise is far from the recommended level figure 2 shows the reasons for not engaging in regular exercise the main reasons reported are lack of time no interest academic stress and a lack of friends the students level of exercise is far from the recommended level figure 2 shows the reasons for not engaging in regular exercise the main reasons reported are lack of time no interest academic stress and a lack of friends the students level of exercise is far from the recommended level figure 2 shows the reasons for not engaging in regular exercise the main reasons reported are lack of time no interest academic stress and a lack of friends living habits and lifestyles may be correlated with screen time table 2 shows an analysis of the correlations between screen time and sleeping time vegetable intake fruit intake and exercise level only time spent on social media websites was found to correlate with sleeping time with statistical significance figure 3 shows the perceived impact of screen time on daily life and health eye discomfort effects on studies a lack of sleep and a loss of concentration were reported as the major issues resulting from prolonged screen time living habits and lifestyles may be correlated with screen time table 2 shows an analysis of the correlations between screen time and sleeping time vegetable intake fruit intake and exercise level only time spent on social media websites was found to correlate with sleeping time with statistical significance figure 3 shows the perceived impact of screen time on daily life and health eye discomfort effects on studies a lack of sleep and a loss of concentration were reported as the major issues resulting from prolonged screen time table 1 reveals that students emotional status is a cause of concern with 22 feeling emotional distress that affects their daily activities and 424 feeling sad a hopeless and seeking help from others table 3 shows the correlations betwe emotional status and livi habits lifestyles screen time and ptsd the variables sleeping time low fr intake low level of regular exercise excess time on social media websites a p 0001 table 1 reveals that students emotional status is a cause of concern with 224 feeling emotional distress that affects their daily activities and 424 feeling sad and hopeless and seeking help from others table 3 shows the correlations between emotional status and living habits lifestyles screen time and ptsd the variables sleeping time low fruit intake low level of regular exercise excess time on social media websites and symptoms of ptsd were found to have significant correlations with emotional status logistic regression was performed to identify the independent factors significantly associated with poor emotional status sleeping less than 6 h spending over 2 h on social media websites and ptsd were independent variables found to have higher odd ratios of 162 177 and 586 of poor emotional status respectively students with regular moderate or vigorous exercise had a lower odds ratio of 065 of poor emotional status shss are a key source of preventive care for students in hong kong with the high prevalence of unhealthy living habits and lifestyles and poor emotional status the low uptake rate of regular attendance to shss should be explored all primary and secondary students can enroll in shss to receive services that meet their health needs at various stages of their development including physical examinations screening for health problems related to growth nutrition psychological health and behavior and individual health counselling and health education figure 4 shows the reasons for not using shss regularly having a lack of time being unfamiliar with the service stressing over academic work and being doubtful of the usefulness of the services are the main reasons for not using them regularly to improve shs attendance 497 of students suggested that the services be organized within school hours and 407 suggested that the services be organized within the school premises at various stages of their development including physical examinations screening health problems related to growth nutrition psychological health and behavior a individual health counselling and health education figure 4 shows the reasons for n using shss regularly having a lack of time being unfamiliar with the service stressi over academic work and being doubtful of the usefulness of the services are the m reasons for not using them regularly to improve shs attendance 497 of stude suggested that the services be organized within school hours and 407 suggested t the services be organized within the school premises discussion this study found an inadequate sleeping time among adolescents the americ academy of sleep medicine recommends that teens aged 1318 years sleep 810 h per h for optimal health 32 the prevalence of short sleep duration among high sch students in us national youth risk behaviors surveillance was found to be 727 3 our study found that 283 of students slept less than 6 h and that 815 slept less tha h similar patterns were reported in other asian countries such as taiwan 34 and ko 35 and the average duration of sleep was 49 h in a korean study 35 the adolesc sleep working group reported that processes involved in regulating sleep timing se to be altered to favor late nights across adolescent development 36 the group a discussion this study found an inadequate sleeping time among adolescents the american academy of sleep medicine recommends that teens aged 1318 years sleep 810 h per 24 h for optimal health 32 the prevalence of short sleep duration among high school students in us national youth risk behaviors surveillance was found to be 727 33 our study found that 283 of students slept less than 6 h and that 815 slept less than 8 h similar patterns were reported in other asian countries such as taiwan 34 and korea 35 and the average duration of sleep was 49 h in a korean study 35 the adolescent sleep working group reported that processes involved in regulating sleep timing seem to be altered to favor late nights across adolescent development 36 the group also observed the trends of adolescents and young adults growing up in an electronic age and states that electronic exposure in the evening potentially disrupts sleep 37 our study found a high prevalence of media use amongst students this was particularly the case during the covid19 pandemic as a result of school closures and with electronic media being the main channel of communication 11 engaging in a greater number and range of sleepinterfering activities such as the use of electronic media before going to bed has been shown to be associated with less nocturnal sleep and more daytime sleepiness in adolescents 38 our study showed that a higher proportion of students use social media websites less than 2 h daily with a sleeping time over 6 h with statistical significance media use can cause increased sleepdisrupting mental emotional and physiologic arousal 39 this might reflect the reasons for sleep disturbance such as failing to fall asleep nightmares and waking up in the middle of the night or early morning as well as the impact of excess screen time such as eye discomfort effects on studies a lack of sleep and a loss of concentration the prevalence of emotional disturbance was found to be high in this study and it was found to be significantly higher among students with unhealthy living habits including poor sleep insufficient sleep time and spending excess time on electronic media sleeping less than 6 h and spending over 2 h on social media websites were found to have higher odd ratios of poor emotional status which was analyzed using multiple logistic regression selfreported sleep variables such as trouble sleeping tiredness nightmares and being a long sleeper have been found to be significantly associated with psychological symptoms including anxietydepression and withdrawal 40 students who do not get the recommended amount of sleep for their age are at increased risk for chronic conditions such as diabetes obesity and poor mental health as well as injuries attention and behavioral problems and poor academic performance 323741 the quality of sleep is related to sleeping hours as this study found that 515 of adolescents getting less than 6 h sleep reported poor sleeping quality compared with 221 of those getting 6 h or more sleep and this was found to be statistically significant sleep quality is as important as sleep duration in predicting future health but it is often overlooked 42 studies have found very strong evidence tying sleep quality to the development of mental disorders as it can more than double the risk of depression and anxiety 42 a previous study has shown that adolescents spending more than 3 h per day on social media may be at heightened risk for mental health problems particularly internalizing problems 43 a poorer sleep quality can be a mediator on the pathway to internalizing problems 44 poor emotion regulation and a lack of social interaction may also be associated with social media use and contribute to symptoms of anxiety and depression 45 however adolescents may turn to social media as a form of escapism perhaps to relieve emotional distress the results of a longitudinal study revealed that increased time spent on social media was not associated with increased mental health issues across development when examined at the individual level 46 emotional problems are multifactorial involving personcentered characteristics such as biological predispositions coping mechanisms and experiencing certain situations such as traumatic events and prolonged exposure to stress and sleep quality time spent on social media is an important factor associated with mental health problems as the study conducted by riehm at al found that if adolescents who used social media for more than 30 min per day instead used it for 30 min or less there would have been 94 fewer high internalizing problem cases and 73 fewer high externalizing problem cases 43 however the findings from the study conducted by coyne et al suggest also examining the context and content surrounding social media use and the many other factors that might explain the increase in mental or emotional health problems during adolescence 46 in this study we examined other factors such as living habits lifestyles and symptoms of ptsd as independent variables a major mental health burden was identified during the covid19 pandemic 16 and social unrest in 2019 28 posttraumatic growth defined as the positive psychological changes that happen upon coming to terms with highly stressful events has been found to more likely occur among people with higher posttraumatic stress 47 students were profoundly impacted by the social unrest in the second half of 2019 28 and then they faced the covid19 pandemic so the odds ratio of poor emotional status was found to be very high with symptoms of ptsd screening for ptsd symptoms would enable the early detection of those at risk patient education and social support are important initial interventions to engage the patient and mitigate the impact of the traumatic event and the rapid engagement of treatment early and ongoing social support and the avoidance of retraumatization have been shown to be associated with a good prognosis 48 a systematic review found evidence of a significant crosssectional relationship between unhealthy dietary patterns and poorer mental health in children and adolescents 49 in this study in the univariate analysis a higher proportion of students with a poor intake of fruit were found to feel sad and hopeless the association was not found in the multiple regression analysis overall there was a very high prevalence of a poor intake of fruit and vegetable among students regular exercise was found to be associated with lower odds of having emotional problems with statistical significance in the univariate and multivariate analyses physical activity is well recognized as a key factor in the prevention and management of mental illness including mental disorders such as depression and anxiety as well as the promotion of mental health such as wellbeing 50 physical activity was also found to be a good and effective choice to mitigate the negative effects of the covid19 pandemic on mental health during the first year of the covid19 pandemic 51 a longitudinal study conducted by rosen found an association between low passive screen time use low news media consumption about the pandemic a structured daily routine spending more time in nature and getting the recommended amount of sleep with better mental health outcomes in youth during the pandemic 17 encouraging more physical activity can also help adolescents to spend more time in nature appropriate screen time can improve sleep hygiene and can also have direct effects on mental health cultivating positive lifestyles and living habits providing a physical environment conducive to regular exercise and providing a supportive social environment to help adolescents coping with posttraumatic stress can enhance their emotional wellbeing in the postcovid19 era the home and school environment should empower adolescents to adopt a more structured daily routine regularly exercise and access resources for emotional support the adolescent sleep working group has reported evidence that strongly implicates earlier school start times as a key modifiable contributor to insufficient sleep as well as circadian rhythm disruption 36 the starting time for school should be further explored to enable students to gain sufficient sleep both in quantity and quality the mental health burden among adolescents is a serious concern and it is expected to further increase with the covid19 pandemic the low level of regular utilization of shss will not enable the service to play an active role in preventive care particularly health promotion including mental health 20 the students lack of participation cannot allow the services to focus on the necessary conditions to reduce risk factors and determine the needs of children and adolescents 20 there are limitations to this study selfreporting might not capture all the data however it is the best option during the covid19 pandemic and it also mobilizes the cooperation of youth a crosssectional study cannot investigate causal relationships the findings of associations may still be useful for the planning of a future longitudinal study this study is only based on one district in hong kong the k t district was chosen for a particular reason the district is a pioneer in the healthy city movement and it is also the first district with a governmentcommissioned district health centre the findings can be a useful reference to help the district to strengthen its primary healthcare services in order to target the needs of adolescents with the existing experience and culture of the healthy city movement together with the infrastructure of the district health centre the k t district has the potential to develop a new model of comprehensive adolescent care that is user friendly and promotes the health of adolescents in the context of daily living conclusions the findings of this study reflect the unmet needs of students and provide some insights into the types of services that serve their best interests service providers for adolescents should think outside the box to be more outreaching in order to promote a better living environment for the maintenance of healthy behaviors a systemic review identified the key components of userfriendly youth services 52 these include accessibility staff being supportive respectful and trustworthy actively listening and providing clear information perceived medical competency the assurance of privacy confidentiality and patient autonomy comprehensive and continuity of care youth involvement in healthcare an ageappropriate environment and health outcomes focusing on quality of life the services should be based in the locality where the adolescents live and study the emphasis should be put on a paradigm shift from adolescent health services to adolescent health promotion and the approach should be settingbased health promotion involving the population in the context of their everyday life combining complimentary approaches that include the school setting local community and local primary care providers 5354 the healthy setting approach allows us to explore the influences of interrelationships and interactions between people places programs and policies on health cultivating a living environment conducive to positive youth health 5354 this is particularly important for mental health as primary and secondary preventions are far more cost effective than the treatment of mental disorders local family doctors and the local district health centre are in unique positions to work and engage the key stakeholders adolescents families schools and other local youth services to set this new paradigm data availability statement not applicable acknowledgments the authors would like to express their deepest gratitude to kk wong for technical advice on data analysis the authors would also like to express sincere thanks to the schools and students who participated in the study

studies have shown that adolescents now have a higher exposure to health risks than those in the past and hong kong adolescents are no exception particularly with the social crisis in 2019 and then the covid19 pandemic in 2020 data from health care services for children and adolescents only represent the tip of the clinical iceberg and health profiles including living habits lifestyles data on health status and health service utilization are not always readily available for effective planning to cultivate a healthy living environment in this paper an exploratory study on secondary school students was conducted in one district of hong kong that has the potential and resources to become a healthy city students were found to have a high prevalence of poor sleep quality and quantity excess screen time physical inactivity an insufficient intake of healthy food emotional disturbance including symptoms of posttraumatic stress disorders ptsds and irregular attendance to student health services a multivariate analysis showed that excessive time on social media websites short sleeping hours symptoms of ptsd and a lack of regular exercise were independently associated with emotional distress youth service providers should reorientate student health services moving away from routine services to be more outreaching in order to cultivate a supportive living and learning environment promoting better health for adolescents

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background measuring the impact of scientific articles has been an active research area for the past decade and various methods have been adopted among these citation analysis is one of the dominant means of research evaluation however as citations focus solely on scientific impact and not on the broader societal impact of research many funding organizations and scientific research councils have turned to altmetrics for evidence of the social usage of scholarly articles the term altmetrics was first coined by priem taraborelli groth and neylon in their study to evaluate traces of usage of scholarly documents in online contexts altmetrics refers to a system that tracks and measures the attention received by research objects which can include articles datasets presentations software and tools shared by scholars scientific communities and the public in various online social networks including twitter reddit and facebook these osns have demonstrated exponential growth over the past decade and they connect large numbers of people and facilitate the sharing of ideas and the ability to receive an immediate response from peers due to this rapid response capability osns have attracted the attention of the scientific research community according to hassan et al twitter is among the most widely used osn for information sharing and content dissemination and more than 91 of altmetrics mentions stem from twitter twitter allows the sharing of public or private short messages known as tweets besides twitter affords users various options including the functionality to retweet an original tweet add hashtags to a tweet create lists of relevant tweets and mention another user in their tweet this provides an opportunity for messages to be spread to a wide range of unknown audience members a retweet allows twitter users to share a chosen tweet with their followers while a mention enables them to tag another user in a tweet or retweet various studies have shown the importance of twitter in generating altmetrics data however very few have analysed altmetrics twitter data by means of social network analysis alperin and haustein explored altmetrics data using sna by creating networks of the twitter followers of seven highly tweeted articles and found that sna can improve current altmetrics indicators imran et al analysed twitter social networks using altmetrics data to examine different network properties across academic fields the authors highlight that the properties of these networks vary across the fields similarly didegah and thelwall used sna techniques to analyse researchers who tend to save or tweet articles similar to those that they cite while these studies represent initial attempts to study altmetrics twitter data using sna they do not examine the underlying structure of the altmetrics twitter social network in addition to examining twitter various studies have employed sna on other sources of altmetrics data hoffmann et al conducted a study investigating researchgate 1 an academic social networking site to examine interactions among swiss scholars in the field of management using the eigenvector centrality measure to rank the users the study reported that highprofile scholars are more central and dominant in the network than senior faculty members in a survey of academiaedu jordan reported that the interactions and relationships on the site functioned as an online business card whereby users followed people without personally knowing them yan and zhang conducted a largescale analysis and collected the quantification of scientific reputation of researchers at various levels from 61 us universities the study reported that the scores closely and realistically reflected the institutions research quality lutz and hoffmann conducted a descriptive data analysis to explore various aspects of r g followersfriends networks they found that seniority is highly correlated to publication impact which further leads to an increase in network centrality many studies have shown that sna techniques can be used to mine complex user interactions by employing graphbased spectral and probabilistic approaches notably users with similar interests usually have similar subnetwork structures and patterns when these are represented in the form of a social network similarly users with unique patterns of interactions across the network can be identified from their position and local neighbourhood within the network sna provides practical methods to discover patterns in complex networks keeping the complex dynamics of altmetrics data in context the authors leveraged sna approaches to investigate both the microscopic and macroscopic properties the objectives of this study are to address the following research questions what type of user accounts are influential in the altmetrics twitter network does the altmetrics twitter network satisfy the smallworld property the rest of the article is structured as follows section 2 provides a brief overview of the dataset and social network formation section 3 investigates both the microscopic and macroscopic properties of the altmetrics twitter network using sna approaches including centrality measures community detection and recurring patterns finally section 4 concludes the article and discusses future directions twitter social mention network this study uses the dataset released by altmetriccom on june 14 2016 this version of the altmetriccom dataset contains approximately 45 million json files each containing information on a single publication altmetriccom captures mentioning of scholarly publications in various online contexts by tracking digital object identifier use and certain domain names because altmetriccom does not include citation counts for publications the count for each scholarly object in this dataset was obtained using the scopus api for more details about the dataset see hassan et al from this the authors obtained a subset of all scholarly articles published in 2015 that had at least one citation and at least one tweet with at least one user mention as captured by altmetriccom the authors had chosen to limit the dataset to articles with at least one citation in order to have a manageable dataset on which to apply network analyses the final dataset for this study is over 14 million tweets corresponding to 77757 scholarly articles note that these selected publications comprise 152 of all scopus publications indexed in altmetriccom in 2015 the selected data consist of the following attributes tweet id altmetriccom id screenname screennamemention retweet mention subject field and date of publication here the tweet id and altmetriccom id are unique ids representing the tweets and articles respectively however there can be a onetomany association between altmetric id and tweet id as a single article can be tweeted many times the screenname attribute represents the user who tweets while the screennamemention attribute represents the user who is mentioned in the tweet both the screenname and the screennamemention attributes were used to create the social network which has been termed as altmetrics twitter social network formally the atsn is an unweighted directed graph g where v represents a set of vertices v 1 v 2 v n and e is the edge set the authors constructed a directed edge between u à v which indicates that u mentions v and an adjacency matrix a where a uv 1 where there is a directed edge between node u and v and 0 otherwise the total numbers of nodes and edges in the network are 149830 and 374822 respectively further statistics including average degree average path length component ratio and weakly connected components are shown in table 1 it can be observed that more than 98 of the nodes form a giant component within the network the visualization of the network is presented in figure 1 for a better presentation of the visualization only the 3206 layout nodes that have a total degree 30 are displayed different coloured nodes represent the various communities in the network while the size of the nodes depicts their eigenvectors centrality values among the eight communities that individually comprise over 1 of the network size two communities appear to be the largest with more than a 20 share of the whole network the network demonstrates a colorwise community structure nodes of the same colors belong to the same community for better visualization nodes of total degree 30 are filtered from the network this visualization is performed in gephi using openord and forceatlas layouts on a setting to prevent overlap the colors were assigned automatically using a communitydetection algorithm and the size of nodes is determined by the eigenvector centrality measure with min size 10 and max size 30 note that 214 of the nodes remain after filtering the network with total degree 30 investigating the microscopic and macroscopic properties of atsn in this section the microand macrolevel properties of the atsn are presented first the microlevel properties are investigated to reveal the networks influential users then the macrolevel properties are investigated to reveal the community structure of the network note that gephi was used to conduct the required analysis twitter influential users to find the influential users in the social network the notion of centrality was used which is a wellknown concept in sna the centrality measure computes the global and local influence of the nodes by mining their connectivity within a network over the years a large number of centrality measures have been proposed among them eigenvector centrality is one of the most widely used for finding central nodes in social networks in the context of the atsn the important nodes are those mentioned by other nodes note that the importance of a node can be computed using a simple sna measure such as indegree centrality however this fails to capture the importance of a node with fewer mentions and a node with a low indegree may yet be relevant with the above considerations the eigenvector centrality measure was chosen to identify the important nodes in the network since it is based on a network spectrum which capture a global view of the whole network through an adjacency matrix the measure computes the centrality of nodes with respect to the centrality value of its neighbors its mathematical formulation is shown in eq 1 𝐴𝑥 𝜆𝑥 where 𝜆 is a normalization constant a is the adjacency matrix and x is the vector of the eigenvalue scores using the eigenvector centrality measure the top 20 influential users are presented all the top 20 influential users are organizational accounts associated with highly reputable journals which demonstrates their dominance in the atsn table 2 shows that organizational accounts associated with journals play a significant role in altmetrics and that most of these journals are in medical fields among the influential users found plos one has the highest eigenvalue and the mining community structure communities are subgroups of nodes that are densely connected to their members and sparsely connected to the rest of the network complex realworld networks have abundant hidden information that is not easily detected by simple observation however most of that information can be extracted by analyzing the community structure of the networks in order to explore the community structure of the atsn a stateoftheart communitydetection algorithm invented by blondel et al was deployed this algorithm uses a heuristic modularity optimization approach that works hierarchically to provide competitive results concerning modularity and time note that the algorithm is based on a greedy approach in order to optimize modularity that has time complexity of o the modularity is scaled between 1 and 1 and evaluates a given community by measuring its interand intralinkages the blondel algorithm utilizes heuristics since finding all combinations of the nodes to form the community is a far from trivial task first the algorithm optimizes the modularity of all nodes by generating small communities second these small communities are coupled to form relatively larger groups these steps are repeated until the modularity has converged using the blondel communitydetection algorithm in gephi eight major communities were identified in the network next the subject fields of these selected communities were identified by matching the twitter profiles of the top five influential users in each community a list of the selected users along with their subject fields and account types is attached in appendixa table a1 among the selected eight communities community 22 was found to be the most significant covering 23 of the users in the network the top five influential users of this community included jama thelancet bmj and nejm all organizational accounts associated with medical journals it was discovered that all the important user accounts in community 22 are in the field of medicine so it was labeled as such in addition to medicine certain fields are prominent such as biological sciences environmental sciences social sciences and the emerging field of data science the emerging community of data science ie community 5 covers over 5 of the network and includes wellknown data scientists including albert barabási and shannon mcgregor note that figure 2 highlights only the major communities that are commonly found in altmetrics data a number of other fields or subfields such as computer science physics and mathematics are not discernible which may be due to the exclusion filter applied to the nodes degree ie 30 overall the analysis reveals that the top influential users of each community are either organizational accounts associated with wellknown journals or leading scholars in a particular field large communities such as communities 22 3 and 20 are dominated by wellknown journals that can influence a giant component of the network by contrast the relatively small communities such as communities 5 and 32 are dominated by top scholars in to their respective fields who may have an influence on only a small subnetwork it was also found that the community size distribution closely follows a powerlaw distribution no of nodes communities in order to investigate the presence of scholar and journalorganizational accounts the method proposed by costas et al was employed see figure 4 in which green nodes represent scholars while gray nodes depict nonscholars note that the size of a node highlights its importance in the network one can see that the green nodes are rarely influential which again emphasizes the significant role of journalorganizational accounts in the atsn analysis of overlapping communities across fields community overlap is a significant feature of many realworld networks it is known that people in a social network naturally have multiple community membership for example in a social network a person may interact with several social groups such as family colleagues and friends similarly in the atsn a scholar may be active across various subject fields in this subsection the twitter users who mention scientific articles across subject fields are identified following the work of haddawy et al 77757 selected scientific articles were mapped to 17 broad subject fields using the all science journal classification embedded in scopus to find the overlap across the fields a well known jaccard similarity measure was used which may be computed as shown in eq 1 j here u i and u j are sets of users who tweet on scientific articles in two different fields i and j twitteruser communication via motif identification most realworld networks contain recurring patterns known as network motifs building blocks of networks that occur at numbers higher than those in random networks the underlying structure of the various natural networks varies likewise these may have a distinct network motif for example the motifs shared by the word wide web network are unlike the motifs shared by proteinprotein interaction networks nonetheless their identification exposes various kinds of interactions found in realworld networks studying motifs in the atsn can enable identification of recurring patterns to do so the randesu algorithm developed by wernicke was implemented in the fanmod2 tool for the analysis the full enumeration option was chosen during the setup of the tool and the process generated 1000 random networks only those motifs whose z values were greater than 2 were chosen the value of z can be computed as shown in eq 2 𝑍 01 2 3 4 3 where x is the number of times motif x appears in the network 𝜇 is the mean number of times it appears in the random graph and 𝜎 is the standard deviation of the motif appearing in the random graph when z 0 motifs occur less often than in random networks and for z 0 the motifs occur more often than in random graphs a value of z 2 is significant as its probability of occurring by chance is 5 than less popular users this motif suggests that user c mentions a and b and users when considering all of the motifs presented above in figure 6 it becomes clear that the commonality between them is the existence of wellknown users for example user a is endorsed in every motif created such types of nodes also referred to as hubs are commonplace in realworld networks hubs have significant impact on network topology and serve to distinguish realworld networks from random networks furthermore hubs both play a significant role in information diffusion and influence propagation in social networks the second prominent aspect of the atsn is the strong connectivity among subgroups of nodes which reflects frequent interaction among users leading to the community structure of the network the high z value of motif 1 clearly demonstrates the existence of strongly connected components in the atsn there may also be more than one hub in a single community which further helps to increase the interaction ratio among the members of that community motifs 2 and 3 can appear in large communities such as medicine and environmental sciences smallworld property test realworld networks differ from random networks in that they have different unique properties random networks have a binomial distribution which can be approximated by a poisson distribution in the k n limit in contrast the degree of distribution in realworld networks is quite different most of the realworld networks appear to be scalefree networks and follow a powerlaw distribution watts and strogatz studied the dynamics of smallworld networks and presented a model to generate such networks a smallworld network satisfies two properties first it has a high average clustering coefficient this quantifies the connectivity of nodes in their neighborhood and is defined as the fraction of the number of existing edges between neighbors of node i among all possible edges between these neighbors the average clustering coefficient is shown in eq 3 𝐶 8 9 𝐶 8 where c i c ∈ 01 second the short average path length log which represents the globalscale property of the network is defined as the average path length between all possible pairs of the network nodes as shown in eq 4 𝐴𝑃𝐿 9 𝑙 bc bc∈e where l uv represents the shortest path length between node u and v p l ij ∞ uv 1n and n 1 p as there is no direct method to test a network for smallworld properties the following steps were undertaken checking for the criteria 𝜆 ≈ 1 and 𝛾 1 following the steps mentioned above the apl of the network was initially determined by taking the large connected component into consideration as the network was disconnected note that the lcc covers more than 98 of the nodes of the network to generate an appropriate ensemble a fast random networks model was used with the same number of nodes and the probability was set to 000048 there were 100 random networks generated the apl and average lcc were computed in order to compare these to the original graph the experiment resulted in a 0913 value for 𝜆 and 21355 for 𝛾 which demonstrates that the atsn satisfies smallworld characteristics and has a structure unlike that of a random network concluding remarks this study explored multiple aspects of the atsn using an sna approach it was found that organizational accounts associated with highly reputable journals such as plos one nature and science play an essential role the authors showed that due to these accounts influence the network forms a giant component covering more than 98 of nodes moreover the community structure of the network was examined and found to have fieldwise high intraconnectivity resulting in a fieldwise community structure large communities are dominated by organizational accounts associated with journals while small communities are dominated by experts in the field as expected substantial overlap was found between relevant fields for example the overall this work demonstrated a novel approach to examining the atsn we showed that twitterbased social media communities have different characteristics while some communities are highly interconnected others are highly coupled yet have low interconnectivity such characteristics may affect social media usage counts either directly or indirectly instead of regarding altmetrics as a black box researchers and consumers of altmetrics should consider the underlying social media networks that may be either inflating or deflating the measures of social usage therefore a more comprehensive examination is advised before adopting these very promising altmetrics indices in future the authors plan to normalize the effect of influential users that may give rise to bias in generating social usage data in twitterbased altmetrics future work will include a comparison of various communitydetection algorithms using the atsn finally future studies should be conducted on even larger data irrespective of citation count as this is one of the potential limitations of existing studies using the aforementioned fanmod tool triplets were detected and six different motifs with z 2 were found as shown in figure 6 the first motif has the highest z value meaning that it is fully connected which implies that most of the time the users mention each other in a closed circle of the network for example the first motif indicates that user a mentions b and c user b mentions a and c and user c mentions b and a this type of pattern is quite common in online social networks due to strong ties and because the strong triadic closure property is satisfied the second most common motif demonstrates that lessconnected users usually mention the networks influential users and influential users are more likely to mention each other in simple terms popular users always receive more endorsements from their followers appendix a this section presents the top 5 influential users from each community with their fields and types field attribute represents the subjectfield or domain of the user which helps to understand the community structure of the network note that subjectfield andor domain is manually extracted from the twitter users profiles to properly label the influential users there are eight major communities which cover more than 98 of users of the whole network

social networking sites play a significant role in altmetrics while twitter originates more than 90 of altmetric mentions the known microscopic and macroscopic properties of twitter altmetrics data are limited in this study we present a largescale analysis of twitter altmetrics data using social network analysis techniques on the mention network of twitter users exploiting the networklevel properties of over 14 million tweets corresponding to 77757 scholarly articles this study focuses on the following aspects of twitter altmetrics data a the influence of organizational accounts b the formation of disciplinary communities c the crossdisciplinary interaction among twitter users d the network motifs of influential twitter users and e testing the smallworld property the results show that twitterbased social media communities have unique characteristics which may affect social media usage counts either directly or indirectly therefore instead of treating altmetrics data as a black box the underlying social media networks which may either inflate or deflate social media usage counts need further scrutiny

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the researcher was fortunate to conduct diversity research in one of the most dynamic educational organizations in the country it was a rare opportunity since like most other organizations in the philippines this company had never allowed researchers access to its employees and internal culture the specific objectives of this study were to a identify the diversity characteristics of employees in the context of a perceived homogeneous culture in terms of age gender tenure and position b examine the relationship between perceptions of diversity inclusion and organizational climate and c investigate the relationship between diverse characteristics and organizational climate methods table 1 diverse characteristics of the sample characteristics procedures a consent form with information about the studys purpose and the significance of participants participation was first obtained those who gave their consent were able to continue with the study forty participants responded to an online survey through google forms the data collection instruments utilized in this study were divided into four parts profile of the participants diversity climate perception scale inclusionexclusion scale and organizational climate scale these scales show a good model fit internal consistency and crosstime consistency with evidence for content convergent and divergent validity measures diversity characteristics participants were asked to indicate their age gender tenure and position while the personal dimension contains personal diversity value and comfort with diversity all items are added to create a composite diversity perceptions score including four reversescored questions that aim to prevent a response set the scale uses a sixpoint likert scale ranging from strongly disagree to strongly agree higher scores on the scale indicate a favorable opinion of a diverse climate asian additionally the dimensions and factors can be separately summed and analyzed to learn more about how employees perceive diversity finally the scale and its factors demonstrated strong to adequate internal consistency with cronbachs alphas of 83 86 80 77 and 71 respectively inclusion mor barak measured the perception of inclusion using a 15item scale the inclusionexclusion scale was developed to gauge how much an employee feels a part of critical organizational functions like information access involvement and participation and influence over decisionmaking it uses a matrix system with three inclusion dimensions intersected by five workorganization system levels the scale items are added to prevent a response set to create a composite inclusionexclusion continuum score with three reversescored questions it uses a sixpoint likert scale ranging from strongly disagree to strongly agree higher scores on the scale correspond to a greater sense of inclusion the initial version of the measure showed good internal consistency in a sample of 3400 employees of diverse racial and ethnic backgrounds in a californiabased hightech company with a cronbachs alpha of 88 furthermore the 17 scale has regression weights from the confirmatory factor analysis on the second 50 of the data suggesting that each scale is factorially distinct highly statistically significant and has acceptable levels of reliability asian journal of multidisciplinary data analysis following the data collection the researcher utilized spss statistics 290 to perform accurate data analysis and presented the results in tables in line with the studys objectives descriptive statistics were first used to ascertain the diversity characteristics of the employees and the level of the measures next a pearson correlation coefficient examined the relationship between organizational climate inclusion and diversity after that several welchs anovas were conducted to investigate group differences for unequal sample sizes of diversity characteristics to organizational climate results descriptive analysis table 2 displays the means and standard deviations of the organizational climate diversity and inclusion in addition a percentile range was created for each measures score to ensure uniformity in interpretation the results show that participants perceptions about diversity m 385 sd correlation analysis table 3 on the other hand shows the relationships between the three measures diversity perception was both significantly and favorably correlated with inclusion and organizational climate however there was no statistically significant association between the organizational climate and the perception of inclusion analysis of variance the relationship between four diversity characteristics and organizational climate is shown in table 4 welchs analysis of variance revealed no difference in the relationship between age and organizational climate however a significant relationship between gender and organizational climate was found by welchs anova the anova posthoc test dunnett t3 suggested that genderdiverse employees had a more favorable perception of the organizational climate followed by women and men likewise welchs anova of the relationship between tenure and organizational climate revealed a significant difference fwelch 317223 discussion and analysis this study aimed to identify filipino employees diverse characteristics in a perceived homogeneous culture examine the relationship between perceptions of diversity inclusion and organizational climate and investigate the relationship between diverse characteristics and organizational climate in the filipino cultural context results indicate that diversity climate was significantly and favorably correlated with inclusion as the study predicted it is consistent with previous research on the association between diversity and inclusion in the workplace furthermore participants views of diversity and inclusion within their organizations were generally fair similarly llantos found that academic managers and leaders of selected higher education institutions in the philippines believed that multiculturalism and diversity management should be embedded in organizational programs it means that filipino organizations are moving towards diversity and inclusion similarly diversity perceptions and organizational climate were positively correlated however the present study has found an insignificant relationship between the organizational climate and the perception of inclusion nevertheless participants viewed relatively their asian journal of multidisciplinary research review issn 2582 8088 volume 4 issue 4 july august 2023 © 2023 all rights reserved by the law brigade publishers organizational climate cho and mor barak argued that peoples perceptions of their organizations can be influenced by their diverse characteristics even though they differ from one culture to another as such it seems reasonable that people identify themselves based on their diversity characteristics and this actual diversity would then affect their perception of the organizations climate including its inclusive practices in addition this study identified four diverse characteristics such as age gender tenure and position with organizational climate however the age factor was not statistically significant with the organizational climate it seems plausible given that most of the participants in the sample were relatively young only gender tenure and position were closely linked to employees positive perceptions of the organizational climate more specifically genderdiverse employees new employees and those in teaching positions have a more favorable perception of the organization the findings suggest a more positive view of the organization among employees in teaching positions since the sample is from a tertiary educational institution hastings also argued that it is likely for new employees to have a more positive outlook than tenured employees however they taper off over time in the philippines heis implementing genderfair learning and gender mainstreaming efforts have facilitated gender diversity awareness among universities and college workplaces in sum assessing the organizational climate is highly relevant in promoting and improving inclusion and diversity in the workplace it is essential to remember that employees can get along with each other but that does not change the fact that they are still different from one another thus while the philippine organizational culture may seem homogeneous it is diverse conclusion in the present study key findings show that most employees have average perceptions of organizational climate diversity and inclusion additionally perceptions of inclusion and organizational climate were significantly and favorably correlated with perceptions of diversity however there was no statistically significant association between the organizational asian journal of recommendations organizations should emphasize the value of diversity management competencies consideration should also be given to developing a diversity management strategy that highlights each employees unique attributes and interpersonal relationships furthermore this study also provides many possible directions for future research it is recommended to replicate this study using samples from different types of organizations such as comparing employees of public and private organizations and those of small and large enterprises in the country limitations some limitations in this study require careful interpretation of the results the sample size was limited to 40 employees at one of the tertiary schools in cebu philippines participants in the study also had short organizational tenures and were relatively young in addition this company had never given researchers access to its employees and internal culture due to the traditional confidentiality of filipino companies the sample was not randomly selected due to the lack of a sampling framework and time constraints nonetheless this was a rare opportunity to conduct the study additionally the study was restricted to a single company in cebu city to maintain sample homogeneity as such the findings may need to be more generalizable or representative of filipino culture despite these limitations the information obtained in the present study offers a unique insight into the diversity of the filipino workforce asian journal of

there is a misconception that diversity is irrelevant to understanding the workplace in other parts of the world particularly in asia in other words countries in asia like the philippines are homogenous today western countries and other developed regions are not the only places where the workforce is becoming more diversified hence this study aims to make a unique contribution to the diverse literature in the country by examining the relationships between diversity inclusion and organizational climate in the context of a perceived homogeneous culture the influence of demographic characteristics like age gender tenure and position was also considered in the study using a sample of 40 filipino employees in a higher education institution in cebu city the results show average employee perceptions about diversity inclusion and organizational climate the perception of diversity was positively linked to inclusion and the organizational climate however perceptions of inclusion and organizational climate were not statistically meaningful on the other hand gender tenure and position were closely linked to employees perceptions of the organizational climate specifically genderdiverse employees new employees and those in teaching positions have a more positive perception of the organizational climate therefore assessing the organizational climate is highly relevant in promoting and improving inclusion and diversity in the workplace

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introduction an atmosphere is not an inert context but a force field in which people find themselves it is not an effect of other forces but a lived affecta capacity to affect and to be affected that pushes a present into a composition an expressivity the sense of potentiality and event it is an attunement of the senses of labors and imaginaries to potential ways of living in or living through things kathleen stewart from where i stand in gezi park i can see through the thick tear gas clouds shrouding taksim square protestors wearing construction helmets and goggles and covering their faces with bandanas are trying to impede the riot polices steady march toward the park every 5 min gas masked members of a voluntary ngo rush in and out of the white clouds to save incapacitated protestors on stretchers we have an injured one shouts and the thick crowd opens to let them through until they reach the corner of the park that is used as a makeshift infirmary in the section marked with barricade tape two young people in medical garb receive the injured with an oxygen mask and after first aid and medical examination decide to transfer him to a medical facility suddenly the police start firing tear gas canisters into the park and one of them lands in the middle of the infirmary causing panic before having to leave the park with burning eyes runny nose and difficulty breathing i hear someone from the infirmary yelling at the police at the top of his lungs dont shoot dont you see we have patients here during the gezi protests that shook turkey for weeks in the summer of 2013 such encounters between the police and medical professionals were repeated on a daily basis to quell the massive political mobilization in all major urban centers turkish police treated protestors with what was criticized by numerous international observers including the united nations european union and the united states government as well as human rights organizations such as the amnesty international and human rights watch as excessive and disproportional force against this backdrop of increasing political turmoil volunteering turkish health professionals under the coordination of the national medical syndicate established makeshift infirmaries around protest sites and provided onsite medical assistance to protesters this led to a government crackdown on health workers and professional medical organizations in the face of international criticisms over violations of medical neutrality the confrontation between the government and the medical profession culminated among the protests of the local and international medical community with a new health bill that allowed prosecution of doctors for providing emergency healthcare without government authorization in this article i ethnographically examine the polarized encounter between the neoliberal authoritarian turkish government and medical professionals aligned with social protest during the 2013 gezi protests in turkey 1 exploring the vexed role relies on recognition thus it compromises a formal weakness alongside its partial counterclaim to sovereignty moreover it is the laws of war that regulate and restrict the scope of the states authority in armed conflicts in order to offer a space for the neutral and impartial provision of humanitarian aid in contexts of violence since international law does not precisely regulate humanitarian assistance in times of peace it is particularly hard to establish what counts as humanitarianism in the face of state violence in domestic arenas drawing on anthropological works that have revealed our conceptions of humanitarianism and medical neutrality to be the artifacts of interstate war and suggested their rethinking in the age of intrastate political conflicts this article addresses the conflicting roles of clinicians and the challenges of providing emergency medicine in situations of political violence and social protest in the article i demonstrate how turkish health professionals framed their provision of health services to protestors around and apropos of medical humanitarianism and how the state strived to dismiss their claims to humanitarianism and neutrality by accusing them of partisanship and hence argued against their impartiality by playing one component of neutralityprotectionagainst anotherimpartiality the contemporary debate over the purposes principles and politics of humanitarianism reveals a struggle to define the humanitarian identity this article illustrates a specific instance of this struggle over humanitarian identity in the context of what is here called atmospheric violence the states deployment of riot control agents against civilian populations the concept of atmospheric violence builds on sloterdijks work on the weaponization of atmospheres where he argues that the military use of poisonous gasses in the first world war inaugurated a new era in warfare in which environmental conditions of life rather than the enemys body constitute the main target i introduce the concept of atmospheric violence for two reasons first the concept enables us to understand the technological specificity of riot control agents as a modality of state violence unlike nonchemical means of crowd dispersal atmospheric violence is deployed spatially and atmospherically across generalized territories and acts on the scale of urban environments rather than individual bodies this mediated nature of atmospheric violence enables the state to wield the environment to repress dissent on a massive scale while also giving way to new forms of embodied vulnerability resistance and political agency second the concept renders visible the very physical violence that the use of riot control agents entails the anthropological scholarship on violence has repeatedly demonstrated how certain forms of violence such as structural violence are not easily recognized as violence violence is a slippery concept because it is always mediated by an expressed or implicit dichotomy between legitimate and illegitimate acts atmospheric violence is not often identified as violence per se not only because it is deployed by the states security forces and it is particularly hard to pin down state force as violence but also because of the ideological work of concepts like nonlethal and riotcontrol which trivialize the adverse health risks of riot control agents 2the latter point is especially important for this articles discussion of medical humanitarianism and neutrality the chemical compounds that make people temporarily incapacitated by causing pain and irritation to exposed mucous membranes and skin are banned in international warfare under both the 1925 geneva protocol and the 1993 chemical weapons convention 3 nevertheless tear gas is globally used despite its undetermined health effects illdefined death toll and contentious legality the laws of war that ban the international use of such chemical compounds permit the states to deploy them under the rubric of riot control agents it is ironic that these very same laws also constitute the international legalmoral framework that enables neutral humanitarian spaces in times of violent conflict exploring the juxtaposition of debates over riot control agents and medical neutrality this article shows how the global turn to atmospheric violence brings about new health ethical and political challenges for health professionals working in conflict settings the data for this article are derived from ethnographic observations during the gezi protests indepth interviews with healthcare professionals and extensive media and archival research anthropologists often complain about arriving too early or too late to observe the really large and significant political events and the violent upheavals that descend on their field sites i was fortunate to already be in istanbul for field research at the onset of the gezi protests and to be able to conduct ethnographic observation in taksim square where gezi parkthe center of the protestsand most of the makeshift infirmaries providing healthcare to protestors were located bolstering my ethnographic observations and my informal interactions with volunteering medics i carried out taperecorded and transcribed indepth interviews with three physicians and two nurses who played an active role in the establishment coordination and delivery of voluntary health services at protest sites my participants were recruited through a combination of snowball and purposive sampling methods although not statistically representative my interview findings exemplify the perspectives of the health professionals who aligned themselves with the protestors especially given that two of my interlocutors have served on the administrative board of the istanbul branch of the turkish medical association i also examined print visual and social media coverage of the protests and the reports publications and press releases of the turkish medical syndicate international medical and human rights associations and the turkish ministry of health i analyzed both my interviews and my archival material using discourse and narrative analysis methods to identify and examine the ethical and political claims around humanitarianism neutrality and atmospheric violence paying particular attention to their textual and enunciative strategies and affective and performative dimensions in what follows i use the findings of this research in order to examine the confrontation between the turkish government and health professionals to address the following questions what were the discursive and material practices through which turkish medical professionals made a medicopolitical intervention to care what happens when the discourses of medical humanitarianism are employed not by international humanitarian organizations but by local health workers actively partaking in a political conflict how do contestations over medical neutrality unfold in a politically charged context characterized by an increasingly polarized relationship between the state and medical professionals what are the challenges that bedevil our understandings of humanitarianism and neutrality when claims to medical humanitarianism are confronted with atmospheric violence the gezi park protests the state and the medical profession the gezi park protests started in may 2013 when a coalition of activists including environmentalists feminists lgbt activists leftwing organizations professional chambers and righttothecity platforms began an occupy movementstyle sitin in gezi park one of the few remaining green belts in the taksim area taksimthe cosmopolitan cultural and political center of istanbulhad long been one of the most politically charged spaces in turkey designated as the new center of the city in the 1920s taksim square became the spatial symbol of the secular national identity of the then newly founded republic the square became an icon of working class struggle after a massacre that took place there during the international labor day demonstrations on the 1st of may 1977 after the 1990s the square also became the center of a controversial islamist campaign to erect a mosque and to reassert the citys islamic identity finally in the 2000s taksim became the focal point of the neoliberal urban renewal policies of the neoconservative islamist justice and development party which sought to develop the area into a refurbished touristic and shopping center the governments demolition of historic urban landmarks and neighborhoods such as sulukule one of the worlds oldest roma settlements and the consequent displacement of urban poor in the name of urban renewal engendered new struggles for urban rights and for conserving the living and built environment heritage government plans to demolish gezi park and chop down its hundreds of trees to construct a postmodern replica of a late ottoman military barracks to serve as a shopping mall crisscrossed all these political fault lines a turning point took place in the gezi protests around midnight on may 27 when bulldozers started tearing down the protestoroccupied park without it later turns out any legal permission to begin demolition protestors who peacefully halted the demolition were faced with a police dawn raid during which they were pummeled by tear gas and pepper spray and their tents were burned nevertheless anger over police violence and the cult med psychiatry condescending remarks of the prime minister erdog ˘an who habitually referred to the protesters as looters drunkards terrorists putschists and promiscuous only increased the number of protestors 4 eventually the protests turned into an urban uprising on may 31 as millions of turkish citizens took to the streets throughout turkey to voice their grievances 5the gezi protests brought together a wide spectrum of social groups and political actors who felt threatened by the akp governments authoritarian neoconservative and antisecular blend of neoliberalism6 among these were the physicians and professional medical organizations the istanbul branch of the turkish medical association which represents over eighty percent of turkish doctors as a professional organization and trade union was involved in the occupy gezi umbrella coalition from the very start the antagonism between the akp government and the medical profession was multifaceted the akp government regarded physicians who served as statealigned agents of topdown modernization and secularization since the late ottoman era as a sector of the privileged secular elite that vehemently opposed its rule physicians and the akp government were also at odds over healthcare policies medical trade unions like the tma spearheaded the opposition against the governments healthcare reform which they criticized as the neoliberalization and privatization of healthcare the government however held that the physicians were only looking out for their own interests when the full day working act of 2010 prevented physicians from working both in public hospitals and in private clinics amidst physicians objections both the minister of health at the time and pm erdog ˘an accused physicians of being greedy and stealing money from the pockets of the public by taking unfair advantage of their patients by not treating them in public hospitals but in their private clinics the medical organizations argued that such accusations and the new performancebased pay system that brought about excessive working hours for physicians made physicians vulnerable to violence at the hands of disgruntled patients a legal regulation allowing the employment of foreign doctors and the governments continuous attempts to curtail the autonomy and reduce the selfgoverning powers of the tma caused further uproar among professional medical circles all this led to an increasingly confrontational relationship between the government and the medical profession the gezi uprising was neither the first time that turkish doctors confronted governmental policies nor their first mass mobilization after being founded as a professional organization in 1953 in the context of turkeys transition into a multiparty democratic state the tma gained a markedly leftist character in the 1970s like most other trade unions and has remained as such since then following the 1980 military coup progressive turkish physicians within the tma took on new political roles through their involvement in the documentation and rehabilitation of torture victims public denouncement of the states human rights abuses and campaigns against the forced feeding of political prisoners on hunger strikes in the aftershock of the devastating 1999 marmara earthquake which led to a near collapse of state institutions including healthcare services many physicians from the tma also became involved in humanitarian medical aid physicians who voluntarily delivered emergency healthcare services during the gezi protests built on these political legacies to articulate the distinctly political medical humanitarianism that i discuss in the following sections atmospheric violence and medicalized resistance during the protests the police used heavy amounts of tear gas rubber bullets live ammunition and water cannons spiked with chemical agents against the protesters they also beat detained and sexually and physically abused hundreds of protesters as of august 1 2013 the tma collected medical information on more than 8000 injuries due to tear gas rubber bullets water cannons beatings and live ammunition according to their report there were at least five civilian deaths caused by police violence and one hundred six cases of severe head trauma including eleven people who lost an eye the extensive use of tear gas became a striking symbol of police violence during the gezi protests the police used 130000 cartridges of tear gas in the first 20 days of the protests draining the entire annual stock that totaled 150000 cartridges and the government put in a bid for another batch of 100000 cartridges in order to replenish the stock testimonies of protestors and independent reports of medical and human rights organizations illustrated that the turkish police systematically and unlawfully misused tear gas as a weapon on millions of protestors firing canisters directly at them at close range aiming for their heads and using asphyxiating gasses in confined spaces with no outlet for escape during protests riot police gassed mosques schools hospital er rooms restaurants and houses in one of the most comprehensive reports on police violence against protestors the usbased physicians for human rights team concluded that the turkish authorities misused tear gas and that tear gas was used unlawfully as a weapon on a massive scale citing the european court of human rights conclusion in a 2012 ruling that turkish authorities misused tear gas against a demonstrator in what amounted to inhuman and degrading treatment the phr report argued that the excessive and unnecessary use of tear gas constituted inhuman and degrading treatment on a massive scale in light of the echr decision in another report the human rights foundation of turkey reached the same conclusion after conducting 297 medical evaluations of injured protesters and stated that the physical and psychological evidence in each case is consistent with torture cult med psychiatry andor illtreatment intentionally and systematically inflicted on large populations of protesters 7 the deployment of such excessive quantities of riot control agents was meant to shut down the public spaces in which protests were taking place paradoxically the states turn to atmospheric violence emboldened the massive mobilization of the turkish urban middle classes who quickly attuned to the new atmosphere under which they lived one aspect of this atmospheric attunement was the frantic cultural buzz that linked the bodily experience of tear gas to resistance in novel ways as not only being on the streets to protest but also the very everyday experience in the city turned into a sort of sumud 8 tearful eyes runny noses suffocating lungs burning skin and painful sinuses quickly became signs of dignity and resistant agency tear gas tastes like honey said the lyrics of one of the most popular resistance songs walls were covered with graffiti subverting celebrating and humorously glamorizing the experience of tear gas this gas is awesome dude was a favored one tear gas beautifies the skin another read still another interpellated the police you did not need to spray tear gas mister were already sentimental guys resistance also incorporated gendered critiques of atmospheric violence protesters favorite slogan to chant to taunt the police was spray spray go on and spray tear gas take off your helmet drop your baton and lets see who the real man is the protesters resignified their own painful resistance to atmospheric violence as a masculine rite of passage which rhetorically replaced compulsory military service as the primary rite of passage into adult masculinity no daughters hand for those who havent tasted gas one line of graffiti read the attunement of middle classes to atmospheric violence transformed the labors of resistance medicalizing them in unexpected ways within the very first hours of the mass mobilization municipal ambulances provided thousands of surgical masks to protestors which created the visual effect of a mass epidemic or viral outbreak gas masks and dust maskgoggle combinations soon replaced the surgical masks on the front lines protesters also used vicks vaporub in the surgical maskswhich despite their porousness and ineffectiveness in keeping out tear gas continued to be worn by the protesters as if they were medical charms sidewalks shop windows and the tops of street transformers hosted placards reading emergency aid station that housed lemon halves and vinegar solution bottles after the first few days of protests mixed liquid antacid and water also emerged as an innovative treatment to palliate skin eye and throat symptoms people rushed to help one another and affected street animals spraying antacid solutions on each others faces to wash off and neutralize the effects of gasses pharmacies in all major cities ran out of their stocks of antacid medicine and one protester in superhero costume dubbed talcidman offered first aid for those affected by gas with his tank of antacid solution becoming one of the cultural icons of the protest these medicalized practices that were used to increase resilience to atmospheric violence heralded the upcoming 7 8 sumud is an arabic term meaning steadfastness and perseverance that have come to symbolize the palestinian resistance to occupation although the contexts are very different the palestinian notion of sumud as the infrapolitics of the weak and stubborn dignity is very useful to understand the resistant agency described in this article cult med psychiatry 123 mobilization of turkish health workers and the unprecedented politicization of emergency healthcare ethics and politics of medical humanitarianism as mentioned earlier representatives of the istanbul chamber of the national medical syndicate were already among the relatively small group of protestors who resisted the parks demolition yet health workers political involvement changed course when mass protests broke out and the number of injured protestors who could not access healthcare facilities or avoided them out of fear of persecution geometrically increased as individual doctors started to share their cell phone numbers on facebook and twitter in response to the endless pleas for help for wounded protestors on social media the medical syndicate started to coordinate the delivery of healthcare services after the tma posted an online request for assistance an astounding number of over 1000 turkish health workers offered voluntary help with medical assistance in less than a few hours the first makeshift infirmary became operative in the chamber of mechanical engineers in beyog ˘lu sharing its phone number and location through social media with the evergrowing number of wounded protestors and volunteering doctors nurses and medical students this first infirmary quickly expanded into a decentered but wellcoordinated healthcare network of more than twenty aid centers and three permanent infirmaries that were housed in places like parks hotels and mosques these makeshift facilities would constitute the focal point in the ongoing contestations over professional medical ethics medical neutrality and doctors social and political responsibilities all my interviewees who actively participated in the establishment and coordination of these makeshift infirmaries in the first hours of mass protests highlighted the unpremeditated and spontaneous nature of their decision deniz9 a general practitioner with er experience who played an active role both in the social media coordination of triage teams and the spatial reorganization of the workplace infirmary at the chamber of mechanical engineers into an emergency infirmary repeatedly used the metaphor of reflex in our interview to explain her medical involvement during the protests you see all these injured people hundreds of them as a reflex you immediately grab a first aid kit and run to succor thats how a physicians mind works for us it is always like this if there were an earthquake right now thats how a physicians mind would react despite being a proud political activist deniz did not narrate her medical aid to protestors as an act of political solidarity on the contrary her narrative reconstructed her reaction as a habituated and automatic response conditioned by the physicians mindset she was not alone in accounting for the provision of emergency healthcare on the grounds of a stimulus act that bypassed conscious reasoning and hence political contemplation mahir a tma board member and a seasoned political activist also used the notion of reflex and located his motivating force in the visceral register of the physicians subjectivity this was not something our syndicate had prepared or organized for this was a spontaneous feeling to help we already take the hippocratic oath its our duty to provide health service whenever its needed we do it as a reflex regardless of its location it could be for someone on a plane or someone drowning in the sea after earthquake or flood in everyday life while taking the bus or after an accident if you collapse from your chair right now my first reflex would be to intervene i would immediately make a diagnosis check your pulse open your airway if its obstructed resuscitate you if your heart stops and i would do these all spontaneously even though we are at an interview and i am not on duty this is a humane reflex that the hippocratic oath brings about thats what happened during gezi in mahirs account the delivery of health services during protests was a consequence of physicians humane reflexes in the face of the everyday precarity of human beings performatively using the vulnerability that i embodied as a human body at our interview setting to make his point mahir construed doctors mobilization to provide healthcare for protesters as a manifestation of their commitment to the hippocratic oath that demands physicians to be there for patients around the clock and regardless of location it was not only doctors like mahir who gestured toward their adherence to professional medical ethics to justify their practices banu an intensive care nurse who played an active role both in the provision of medical aid and the categorization and stockpiling of the donated medical equipment after initially taking to the streets to protest police violence also referred to the demands of the medical oath i have a social side that goes beyond my identity as a nurse and that is how i was drawn into gezi events i could not remain silent or stay away and knowing that people were harmed i could do whatever i could i dont think i misused my occupation i just used my skills to help people for me this is no different from a postearthquake or flood situation what happened was a natural disaster in my opinion health workers shoulder the same responsibility in a natural disaster being a health worker is not only about working at a hospital and taking care of people who come there the oath you take is above and beyond that although they all actively participated in the protests either as unaffiliated individuals or as activist physicians organized under the banner of the medical syndicate my interviewees understood their medical involvement not as a political gesture but as an inescapable ethical and professional obligation of health workers prescribed by the hippocratic oath all of my informants compared their medical activities with postdisaster medical relief and hence construed the medical situation on the ground as an emergency comparable with natural disasters like earthquakes this notion of cult med psychiatry emergency which imbued my informants narratives with moral force is of key importance to the medical professions claims for humanitarianism and medical neutrality and the states attempts to dismiss them and criminalize unauthorized emergency healthcare as a cultural construct the idea of emergency is an indispensable element of contemporary humanitarian interventions emergency is a way of grasping problematic events a way of imagining them that emphasizes their apparent unpredictability abnormality and brevity and that carries the corollary that responseinterventionis necessary in the context of the gezi protests health workers interpretation of the medical situation in which they operated as a humanitarian emergency was made possible by two main factors the first was the very technological modality of atmospheric violence the way that it acted on the environmental level and transformed the urban ecology like a natural disaster the extensive use of riot control agents indiscriminately affected all urban residents regardless of their political stance in some of the most populated areas in istanbul putting people with respiratory diseases like asthma especially at risk in our interview mahir explicitly dwelled on the specificity of atmospheric violence as he linked the deployment of asphyxiating gasses with humanitarianism the government can of course take preventive measures to protect liberties during social upheavals we are not against this certain means of force such as water cannons and shields can be used we do not object to that either but if you use a chemical weapon like tear gas then youd better have to have organizations like the red crescent and the red cross ready there is this new organization for earthquake preparedness disaster and emergency management authority it should have been ready alongside the police there must have been health workers who could give aid to the injured that was missing during the gezi events ambulances could not enter areas where clashes took place we had to deliver emergency healthcare and we ended up guilty for doing what the state was supposed to do during the course of the protests professional medical organizations collected casualty data compiled medical reports and produced statistics that conferred scientific status to the protestors embodied knowledge of the effects of atmospheric violence a report released by the tma during the protests surveyed approximately 12000 people who had been exposed to chemical weapons up to eight hours a day over multiple days and indicated that 40 suffered from longterm complications 10 the report documented that 39 still complained about continuing effects from exposure at the time of the study 14 said they suffered skin irritations and 10 reported dizziness and balance problems the statistics that were released during the protests documented and discursively produced the medical situation on the ground as an emergency the second factor behind the health workers emergency discourse was the alleged failure of the state to provide adequate emergency healthcare services in protest areas the reports prepared by the tma pointed out the failure of the ministry of health to provide satisfactory emergency healthcare services especially ambulances for wounded protestors according to these reports the public emergency hotline was unreliable and doctors were compelled to use independently operated private or municipalityrun clinics and ambulances the ministry of health denied these allegations in a press statement and blamed the protesters for damaging ambulances the gezi events took place in large cities generally in city centers there was no question of any shortfalls in the provision of health services in those locations… it is greatly unfair to claim that there were shortfalls in the provision of health services during the protests nevertheless just after the protests ended the turkish bar association filed a criminal complaint against the ministry of health for negligence in light of the testimonies of health workers and claimed that the ministry failed to provide a sufficient number of ambulances and doctors despite the gravity of the medical situation depending on the location of their makeshift infirmaries my interviewees had mixed recollections as to the availability of staterun ambulances some suggested that ambulances were dispatched efficiently after the first few days of the protests others argued that they had to make do for weeks and carry injured people to hospitals in cabs or on stretchers chairs and even on shoulders nevertheless as denizs remarks below exemplify all of them agreed that there was a general crisis of trust in the state including its healthcare services first aid was badly needed state hospitals could not help everything was happening on the streets and there was no healthcare service on the street ambulances did not show up he later disowned this statement but the word on the street was that the minister of health said why would i dispatch ambulances for those opposing the state he later refused saying that but that was the word on the street and the ambulances were really not coming they were not coming because the government was acting political but also because people did not trust the state because there is a state that shoots at you at your head with the intention to kill…thus even if the ambulance would show up it would not be able to enter the square it carries the emblem of the state and people dont trust the state also there were rumors about ambulances people believed that they were carrying tear gas in extraordinary circumstances such speculative rumors always circulate i know it from my postearthquake experience what is important is the feeling these rumors convey about the peoples mistrust of the state deniz just like the rest of my informants and thousands of other turkish health workers was first recruited into medical humanitarianism after the devastating 1999 marmara earthquake which led to a collapse of state institutions including healthcare services and widely popular political critiques of the state as corrupt and ineffective in that sense her evocation of the postearthquake setting in her narrative can be understood in relation to the ways in which the 1999 marmara earthquake shaped popular understandings of emergency as a foundational moment in the history of humanitarianism in turkey her emphasis on the entanglement of cult med psychiatry medical and political crises in the postearthquake and gezi protest milieus had another significance protestors mistrust in state institutions in the context of political protests against the increasingly authoritarian akp government once again showed that a wellworking medical system was not simply a question of adequate provision of services a tma survey based on 11155 respondents determined that the rate of hospital referral was around 5 among those who suffered adverse health effects from tear gas exposure11 injured protesters did their best to avoid official health facilities out of fear of being beaten detained or prosecuted by the police indeed while many injured protesters were beaten or detained in police custody in their attempts to seek emergency care in public hospitals doctors who cared for protestors were pressured by the ministry of health to reveal their patients identities as the next section illustrates the turkish medics battle over neutrality would extend such breaches of doctorpatient confidentiality and beatings arbitrary arrest and detention of individuals seeking medical care medics under fire in the first hours of the gezi protests doctors assumed that they would enjoy the immunity conferred on health personnel and travel without obstruction to provide healthcare where needed seher for example a general practitioner who was on night shift on may 31 when mass protests started and followed the events and pleas for medical help through social media decided to go to taksim the following morning only to realize that the privileges she took for granted were on hold i knew that people in taksim were blocked off by police barricades but i said come on ill tell them that i am a doctor and show them my medical equipment and theyll let me in but my friends warned me saying that they treat doctors even worse hide your bag they told me and do not tell that you have medical equipment i had to join a group of protestors who clashed with the police to enter taksim another general practitioner deniz came to the same realization alongside the shopkeepers who welcomed her and her fellow medics with the expectation of establishing their businesses as neutral and safe spaces shopkeepers warmly received us in all places where we wanted to provide healthcare services they had the idea that no one would attack their shops if they opened them to health workers they were thinking we will tell that we have wounded and there will be no attacks you see everybody has an ethical vision about healthcare but then we all came to our senses after the very first hours of mass protests the repression of dissent extended to the healthcare practitioners in a way that was reminiscent of the bahrain governments systematic attack on clinicians 12 volunteer health workers were detained and beaten as the police attacked hospital ers temporary medical aid stations and makeshift infirmaries the media widely circulated footage of a water cannon attack on istanbuls private german hospital near the center of the protests doctors working in the german hospital and in the public taksim hospital reported that tear gas was directly fired at emergency rooms thereby hampering treatment of patients and leading to the hourslong shut down of crucial hospital departments such as radiology 13 reports prepared by the research teams of physicians for human rights and amnesty international documented these abuses including police raids on professional medical organizations these reports as well as the internal reports of the tma demonstrate the systematic nature of the police targeting of healthcare sites and professionals in one incident a group of doctors volunteering in a makeshift infirmary sought relief from excessive tear gas in a hospital nearby but were prevented by the police who aimed and shot tear gas canisters at them after seeing their white lab coats some doctors came to see their coats as invitations for attack rather than protective symbols and eventually removed their coats and other forms of medical identification as my informant deniz put it after a while we had to take off our white coats being identified as a doctor was dangerous because the police immediately targeted us we were not different from a protestor on the street a bird flying in the air or a wandering street dog we were all at risk on june 13 at the end of the second week of the gezi protests the tma stated in a press release that they had refused the request of the ministry of health to reveal the names of the physicians students of medicine and health workers running the makeshift clinics as well as the names of people who received medical care 14 the following day the minister of health stated that the makeshift health clinics were illegal and that medical personnel could face criminal investigation for providing emergency healthcare there 15 on june 15th the minister of eu affairs declared that every single person in the taksim area would be considered a terrorist paving the way for the polices final attack onto the protest sites the video footage of the event shows police firing tear gas and pressurized water at the entrance of the makeshift health clinic at the divan hotel beating people running out of the building removing masks from peoples faces and removing lotion used to treat exposure to tear gas 16 while this episode concluded the physical confrontation between the state and the medical profession their battle continued in the juridicolegal realm 12 during the 2011 protests in bahrain the government launched a systematic attack on medical staff the military organized incursions into hospitals and doctors who treated protestors were abused and arrested and even went missing for a detailed account of the bahraini case see friedrich 13 14 15 16 the medical personnel detained during the protests were eventually released yet the states criminalization of the medical community has continued in other forms the ministry of health after declaring that the makeshift infirmaries were illegal began a post factum legal investigation to determine whether healthcare professionals volunteer efforts comprised criminal activity doctors who volunteered to treat the protestors or to collect casualty data received letters from hospital administrations and the ministry of health informing them that they were under legal investigation and requesting information about their participation in the infirmaries in a letter to the medical journal the lancet the turkish ministry of health spokesperson defended these practices by arguing that rather than providing healthcare the infirmaries actually stood in the way of the delivery of healthcare services protesters set up some socalled firstaid stations no evaluation or medical recordings have been obtained so far these stations were open to malpractice by unskilled people instead of calling for ambulances protesters tried to keep injured people in these firstaid stations and put patients lives at risk in one of these stations some people acting as doctors were arrested they had criminal records according to judicial records and were not associated with healthcare services thus these socalled firstaid stations hampered actual first aid that patients really needed17 the ministry of healths main argument in this letter is that the prevention of malpractice and the provision of standardized healthcare services can only be assured through official control mechanisms in the domestic arena the government focused on conflating doctors with criminals in order to delegitimize the delivery of voluntary emergency healthcare services for example the governor of istanbul stated the detention of three doctors for helping the wounded during the protests was reported in the news professional medical organizations also contacted us for these cases i now announce those individuals wearing medical garbs who are said to be delivering medical aid have nothing to do with medicine and health 18while government representatives assured that no legal action would be taken against the healthcare workers a prosecutor launched an indictment against two medics who had served in the infirmary in the dolmabahc ¸e mosque which became embroiled in an intensely charged national drama the mosque was converted into an infirmary where protestors took shelter after a severe police crackdown on protestors marching toward pm erdog ˘ans office in istanbul pm erdog ˘an claimed that the medics and patients defiled the mosque by stating protesters entered the dolmabahc ¸e mosque with their shoes on consumed alcoholic beverage there and through that acted disrespectfully to this countrys religious sacred places although both the imam and the muezzin of the mosque explicitly denied these claims the government propaganda proved effective in blemishing the medical profession months after the incident the tma issued a press release in front of the mosque to protest the prosecutorial indictment against the medics who treated patients there an old man passing by scolded them by saying is hippocrates our god there is allah you are defiling the mosque19 a few months later the dean of a medical faculty became the center of media attention after he removed the phrase i will not permit considerations of religion nationality race political affiliation or social standing to intervene between my duty and my conscience from the commonly used version of the hippocratic oath and added i take an oath in the name of allah20 these incidents illustrate how even the medical oath itself to which my informants continuously referred to justify their medical involvement in the protests continued to be a subject of political contestation even months after the protests following these contestations the government passed a new health bill that allowed the prosecution of doctors who provide unauthorized emergency healthcare under this legislation health professionals are obliged to apply for official permission to administer emergency first aid without that authorization medical personnel could face one to three years in prison and fines of up to 920000 for treating patients in emergency situations 21 the tma declared that it would not abide by the legislation many members of the international medical community including but not limited to the united nations special rapporteur on the right to health world medical association standing committee of european doctors physicians for human rights and british and german medical associations also condemned the health bill which was seen as limiting access to care and putting doctors in direct conflict with their ethical and professional responsibilities however the akp government stood defiant in the face of international criticism and the bill was passed by the parliament and signed by the president officially criminalizing the kind of emergency healthcare provided during the gezi protests this bill announced that there would be no neutral space for voluntary medics at times of political upheaval and effectively closed the door for any future claims to humanitarian medicine except those recognized by the state difficult categories humanity and neutrality the struggle of medics and medical organizations in turkey brought to light two sets of limits and challenges related to local health workers claims to humanitarian medical practice in times of political upheaval the first concerns the alignment of medical humanitarianism with social protest in the name of humanity throughout the protests the tma had recourse to a discourse of humanity for example in a press release titled humanity and medicine the medical association stated if those resorting to tear gas pressure water and violence have their prime minister the turkish medical association has humanity to be in solidarity with such evocations of humanity provided medics with a moral high ground yet humanity is a contested category whose capacity to evoke compassion for others is matched by its tendency to identify these others as threats states also invoke the category of humanity in order to push certain populations outside the fold of humanity and to render them expendable and killable in the case of the gezi protests while the tma claimed a morally superior commitment to humanity the governments discourse in turn dehumanized the protestors by deploying the rhetoric of terrorism and the morally and religiously charged accusations of desecration drunkenness looting promiscuity and living in urine and feces 22the second set of limits and challenges concern the issue of medical neutrality especially for practicing medics who choose to speak out in their own countries from the onset of the conflict over the future of gezi park the tma was an active party in the conflict and some of the volunteering medics including my informants also took part in the protests as citizens when they were not treating patients my informants did not see any conflict between their explicit political stance and their adherence to the professional principle of no interest above the wellbeing of patients and narrated their medicopolitical involvement in the protests in medicalethical terms medical personnel responded to this particular challenge through various strategies medics humanitarian mobilization following the utter failure of the states healthcare system in the aftermath of the 1999 marmara earthquake was frequently cited as a precedent that legitimatized the role that health professionals played in the gezi protests my informants regularly described the medical situation on the ground as a humanitarian emergency equivalent to the aftermath of a natural disaster for example in a press release that responded to the ministry of healths criticisms the medical syndicate used medics mobilization for postdisaster medical care as a comparable example of their adherence to legal regulations and professional medical norms lets think together what is legal and what is not then lets ask the minister of health on which issue and against whom are you planning to lodge your official complaint in the earthquakes of ko ¨rfez and vanercis ¸ health workers had set up infirmaries and extended health services on voluntary basis were they illegal too another strategy that functioned like the comparison of state violence to a natural disaster to legitimize the provision of medical care was the invocation of a public health threat the states deployment of atmospheric violence played a key role in the construction of the medical effects of state violence as an urgent public health problem throughout the protests medical professional organizations informed the public about how to prevent and protect oneself from tear gas exposure and popularized new methods of protection like the use of antacids they also found innovative ways to campaign for the ban of riot control agents as in the case of the turkish thoracic societys world no tobacco day press release arguing that tear gas exposure is at least as harmful as smoking 23last but not least volunteering doctors continually alluded to their treatment of an injured police officer at the gezi infirmaries as an iconic moment of their neutral stance in a lancet article that criticized the turkish government for its excessive use of force and violations of medical neutrality a representative of the tma recalled the event the police officer had been hit in the head by something that fell from the akm building… there was no ambulance for him and at first the police said we dont want your help but then they saw that it was serious the injured officer had been knocked unconscious and was in a lot of painand they changed their mind nevertheless as i have shown in the previous section the government did not acknowledge these medical humanitarian claims and dismissed pleas for medical neutrality as it launched a crackdown on medics from the governments perspective medics in makeshift infirmaries were not entitled to protection and immunity because they had lost their impartiality by acting in tandem with protestors on the frontlines increasing their resilience in the face of state violence government crackdown ironically produced as truth what was the assumption behind the crackdownthat there was no unproblematic position of medical neutrality during the protests the only way that health workers could now treat patients regardless of their political associations was through active political defiance of the governments criminalization of their services a stance that has been described by the anthropologist peter redfield as active neutrality on the side of victims the medical syndicate assertively voiced this active political stance through powerful public appeals we practice our profession here on this land that once hosted the founders of the science of medicine hippocrates of kos and galenos of pergamon… for thousands of years we have seen many leaders kings and sultans on this land they have all gone as we remain here they will go as well … and we shall continue if this statement claimed political neutrality of the medical personnel through an emphasis on their independence from past present and future political authorities the tmas active and defiant stance made the medical professionals further vulnerable to the ministry of healths accusations of interestedness the healthcare volunteers negotiated an increasingly difficult balance between this explicitly politicized stance and a constant emphasis on the medical commitment to neutrality writing on the international medical humanitarian organization me ´decins sans frontie resdoctors without borders redfield argues that neutrality is not disinterested but rather an instrumental claim a political strategy that under particular conditions can serve the interests of the weak as well as the dominion of the powerful redfields remarks on neutrality as a weapon of the weak help us understand the difficult positioning of the tma which is trapped within the borders of a nationstate between the rival objectives of protecting its humanitarian stance by claiming an operational sense of neutrality as a professional right and claiming moral authority through the engaged stance of speaking out in the case of the gezi protests turkish medics strategic claims to neutrality did not prove successful despite their arguments about humanitarian medicine and impartiality in relation to the protestors and the outcry from the international medical community conclusion the contestation between the turkish government and the medical profession over the meaning and scope of medical humanitarianism neutrality and ethics is a reminder that attempts to circumvent violence while providing services are not the experiences of foreign humanitarians alone but particularly acute experiences of local health workers in setting s of conflict making successful claims to neutrality at times of political conflict is particularly challenging for local health workers who are often accused of political interestedness when attentive to politics mainstream biomedical practitioners are often questioned about compromising their objectivity as if political neutrality were a requirement of objectivity politically sensitive physicians are often subjected to criticisms of biasof placing truth in the service of partisanism while critically analyzing the turkish doctors appeals for neutrality and humanitarian action in the midst of antigovernment political protests in which they partook not only as medical professionals but often also as protestors i do not intend to dismiss their appeals as inauthentic strategic moves hiding political purposes i rather examine the discourses in and through which they construed the medical situation on the ground as a humanitarian crisis in the spirit of the critical scholarship that has demonstrated that the category of humanitarianism is not given but an artifact of various historically produced and socially situated discourses as these social constructivist approaches to humanitarianism have clearly shown us the definition of what constitutes humanitarianism has evolved historically in close parallel with changing forms of humanitarian responses in that sense the kind of politically engaged medical humanitarianism that the health workers claimed in the gezi protests is one among many possible different strands of humanitarianism that are constituted and defined by different configurations of practices principles and understandings of the proper relationship between politics and humanitarianism as evidenced by the tugofwar between an increasingly hostile government and an increasingly defiant medical organization medical humanitarianism cannot be taken for granted as an apolitical concept but becomes a terrain of political struggle during internal conflict it is not only medical humanitarianism that has to be radically rethought in the contexts of political mobilization against the state but also the idea of neutrality which constitutes the practical and ethical core of humanitarian practice as the recent uprisings in the middle east showed us states easily discard claims to neutrality when confronted with massive waves of protest from the perspective of the state local health workers medical aid to wounded protestors hinders the consolidation of state authority in times of political upheaval in such a milieu redfields reminder that the claims practices and strategic significance of neutrality vary under different regimes of power and i would add of violence is more crucial than ever atmospheric violence already has a problematic relationship with the abstract principle of neutrality as its constitutive outside the same international legal regulations underlying the international consensus that sustains the principle of neutrality also allow sovereign states to domestically use technologies of atmospheric violence against their own civilian citizens while banning them as chemical weapons in times of armed conflict under atmospheric violence through which the state politically weaponizes the very environmental conditions that are vital for healthy human life functions such as breathing the fragile fiction of neutrality becomes ever more problematic when the medical humanitarian ethics of sustaining life intersect with atmospheric violence medical care can hardly remain neutral the very technological modality and political purpose of atmospheric violence do not leave room for neutral sanctuary spaces on the frontlines for the medics who align themselves with protestors the akp governments recent criminalization of unauthorized emergency healthcare services constitutes a clear example of how health workers medicopolitical mobilization under atmospheric violence is understood as an important political threat by states with authoritarian ambitions the recent politicized conflicts over medical humanitarianism and neutrality in turkey resonate with the struggles of those providing medical care in times of political conflict in and beyond the middle east in our era of intensifying political discontent and increasing use of atmospheric violence around the globe conflict of interest salih can aciksoz declares that he has no conflict of interest human rights and informed consent all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional andor national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards informed consent was obtained from all individual participants included in the study

during the 2013 gezi protests in turkey volunteering health professionals provided onsite medical assistance to protesters faced with police violence characterized by the extensive use of riot control agents this led to a government crackdown on the medical community and the criminalization of unauthorized first aid amidst international criticisms over violations of medical neutrality drawing from ethnographic observations indepth interviews with health care professionals and archival research this article ethnographically analyzes the polarized encounter between the turkish government and medical professionals aligned with social protest i demonstrate how the context of atmospheric violencethe extensive use of riot control agents like tear gasbrings about new politicoethical spaces and dilemmas for healthcare professionals i then analyze how turkish health professionals framed their provision of health services to protestors in the language of medical humanitarianism and how the state dismissed their claims to humanitarian neutrality by criminalizing emergency care exploring the vexed role that health workers and medical organizations played in the gezi protests and the consequent political contestations over doctors ethical professional and political responsibilities this article examines challenges to medical humanitarianism and neutrality at times of social protest in and beyond the middle east

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and opportunities from developed countries either in absolute or relative terms and these might make their networking experiences different from female entrepreneurs in developed countries throughout this article the author uses the term entrepreneurs networks networks can be defined as entrepreneurs relationships or connections with external parties the external parties would be individuals or organisations furthermore the author uses the verb to network and the participle form networking both meaning the actions by which an entrepreneur creates and develops contacts entrepreneurs form and develop network relationships to acquire required resources and identify business opportunities those who perform and control the resources are called network actors they can be informal or formal organisations according to the nature and objectives of the firm network actors can be divided into four categories social network interfirm network supporting network and business network actors social networks of contacts are made informally through social or nonbusiness activities these contacts may comprise family relatives friends and acquaintances interfirm networks of actors consist of other firms for example small medium and large companies supporting networks of actors consist of government bodies private supporting organisations ngos and banks the supporting network actors primary purpose is to provide various types of support to small businesses finally business networks may include membership in various professional bodies attending seminars and trade fairs etc most of the small firms owned by women cannot achieve their goals by themselves therefore network formation is essential for small and medium businesses to consider when aiming to achieve growth in addition small firms need support and resources from outside organisations and relatives and friends consequently researchers have argued that small businesses success and survival mainly depend on networks support social network theory describes the various relationships between people and focuses on understanding how relationships connecting individuals groups or organizations generate benefits and opportunities for human behaviour some research findings reveal that small business entrepreneurs use networking to improve marketing activities and innovations meaning that networks are precious to small businesses there is a strong relationship between women and the tourism sector womens participation in entrepreneurial activities in the tourism sector is high compared to other industries for example latin america has the highest proportion of female employers in tourism more than double the rate in other sectors in sri lanka finding information on gender participation in the tourism sector is somewhat challenging as little information is available nevertheless an unpublished report from the department of census and statistics in sri lanka reveals that female entrepreneurs were particularly prevalent in the tourism sector compared to other industries in 2016 the tourism sector is characterised by seasonality and informality and the majority of tourism employment is lowpaid and parttime regarding the high number of women working in tourism there is a relationship between this type of work and feminine subjectivities this circumstance makes one wonder if womens presence within the tourism sector is a chicken and egg situation whereby dominant gender structures push women into tourism and whether in turn tourism encourages gendered labour however a report on the tasks women perform within the tourism and how tourism affects women reveals that tourism provides many opportunities for women to become employed as there are low entry barriers parttime work options and everyday work or homebased businesses the connection between the invisibility that women experience when completing domestic tasks and when working is significant as this is internalized as a way of being and subsequently transcends the domestic boundary contaminating womens entrepreneurial intentions in bakass study many of the female entrepreneurs in italy show signs of how their natural role as domestic careers affects their interpretations of entrepreneurship by for example projecting how significant it is for them to help their family by becoming involved in entrepreneurship the importance of building networks relationships exchanging resources knowledge mutual support and developing trust in tourism activities has been emphasised in many studies for example during the covid 19 pandemic valeri and baggio uncovered that for the survival of tourismrelated businesses an effective mechanism for knowledge sharing is essential furthermore building a networking relationship for women to be active in the tourism sector is consistently highlighted in the literature as women are not only faced with the challenges of dealing with economic activities but often also with the challenges of shifting their traditional gender roles in their communities by making incomes becoming businesswomen in the tourism sector the tourism sector is dominated by smalland mediumsized enterprises as well as female businesses both groups usually do not have the resources to generate new knowledge so they are forced to rely on external sources in reality among the various economic fields tourism is where formal and informal cooperation partnership and network are essential for the survival of a business researchers discovered that a lack of networks is the underlying reason why female entrepreneurs experience less success compared to their male counterparts therefore there is essential to identify womens networking experiences and networking strategies to meet these challenges in this setting the study seeks to answer the research question how do female entrepreneurs form and develop their networks in the small business tourism sector in sri lanka literature review the systematic literature review was carried out to identify major arguments and debates circulating in female entrepreneurs networking area this paper reviews the literature on female entrepreneurship female entrepreneurs networks and female entrepreneurs in the tourism sector for over 20 years from 1999 to 2021 the review criteria was based on the prisma publication standards articles for the study were carefully chosen using two leading databases scopus and web of science after screening the titles abstracts and full texts of the retrieved results the researcher assessed the relevancy of the articles and chose only the most relevant studies which met the standards according to relevancy female entrepreneurship much entrepreneurship literature highlights a link between masculinity and entrepreneurship concluding that women who want to be entrepreneurs must follow these ideals as feminine ideals of passivity collectivity and caring are weaknesses in entrepreneurship theorising more recent studies which focus on female entrepreneurship from a feminist approach underscore how different conceptualisations of entrepreneurship are viable such as a recent study challenging womens underperformance myth today it can be seen that female participation in entrepreneurial activities is increasing gradually however female entrepreneurship is still under research area henry et al revealed that it is still vital to research why female entrepreneurship is still an underresearched area across cultures communities and contexts researchers in this area mainly focused on addressing womens financial constraints issues related to competing in a business and family and gender differences in entrepreneurial characteristics in most cases researchers reveal that women are complex multitasking persons who contest traditional gender identities and womens subordinate role is consistently highlighted however few researchers focus on softer issues such as personal networks relationships with other parties have become the most crucial support for female entrepreneurs in both established and aspiring businesses in all sectors similarly literature on emerging entrepreneurial ecosystems emphasises the role of social networks and social capital as major elements in an operating ecosystem female entrepreneurs networks in current literature the female entrepreneurial experience is described through an angle of networking where the relational dimension that explains the networks content has more value researchers have found that gender differences in entrepreneurs constraints in terms of forming and developing networks and these differences may lead to different economic and social consequences in any particular society several studies have shown that women networks include more strong ties however their network composition and content are considered less powerful less wealthy and less heterogeneous than their male counterparts in networking literature some findings revealed that both men and women have a strong desire to network with the same gender contrastingly others find that both genders need to have primarily men therefore the networking relationship would be more critical for women in the early stages of the business giving emotional support and providing solutions to the particular problems that challenge women such as businessfamily conflict or lack of acceptability of women being headed furthermore it can be seen that men hold positions of higher status and fewer family responsibilities in many social structures compared to female entrepreneurs female entrepreneurial networks are the creation of the close association of family and work family is consistently recognised as the main motivation for a business startup moreover other authors argue that an extensive support network can create conflicting demands on the socioemotional attention of female business owners in this setting female entrepreneurs are more expected to struggle to meet the expectations of both those who compliment them for being successful and encourage them to be responsible mothers spouses and daughters simultaneously this norm can result in an inconsistency in womens commitment to a venture thereby negatively affecting their business growth therefore some authors conclude that an extensive network may constitute a disadvantage for female entrepreneurs gender tourism and networks as tourism is created of human networks female entrepreneurs network experience in the tourism sector is an exciting and underresearched area however the role of gender plays in the tourism sector shreds of evidence as women are more likely to enter the tourism sector due to its flexibility and suitability for them to be engaged without challenging social norms regarding womens roles as housewives an example of women in tourism businesses that follow societal expectations related to feminine predispositions of care is womens involvement in making craft products to sell to tourists as is the case with mexican weavers and mayan craftswomen as these women can work on their craft production at home they are perceived as also being able to combine a business activity with childcare thus they conform to feminine subjectivities connected to care in addition some women convert part of their house into a guesthouse or restaurant for tourists thereby simultaneously staying at home and engaging in business in effect most women who engage in tourism undertake work that is a natural addition to their daily housekeeping such as cleaning cooking and welcoming guests despite the potential that exists for female entrepreneurs in the tourism sector women are facing unique issues and challenges such as social and cultural norms than men in starting and running their businesses as well as in accessing economic resources female tourism entrepreneurs face unique problems such as seasonality and long days affecting how they negotiate the activities needed to continue domestic life daily and intergenerationally besides the gender norms rooted in societies limit womens participation in social and business activities therefore it is essential to explore further the underlying grounds that determine gendered choices regarding participation in tourism activities gender forms part of the main problems addressed by kinnaird and hall who argue that constructions of gender relations are contextspecific aitchison kabil et al and khatiwada and silva are examples of academics who critically review the role gender plays within tourism adding to the body of literature that kinnaird and hall started aitchisons focus on sociocultural relationships follows the cultural trend within tourism studies proposing a focus on both the material and the culture as the spaces where gender identities and connections are reworked pritchard argues that tourism research must address the social relations such as gender that strengthen tourism processes by connecting empirical examples to theory to support the call for more critical analyses of tourism however focusing more specifically on the role that gender plays in tourism research few academics have embraced this subject apart from tuckers longitudinal study on female entrepreneurs in turkey moreover the literature reveals that womens contribution to business and economic growth is almost certainly underestimated many women work in the informal sector and their business activity is not reflected in national statistics particularly in developing countries such as sri lanka in general womens businesses have high failure rates and are less successful in financial performance than their male counterparts further female entrepreneurs engage in lowvalue sectors such as tourism handicraft garment and other service sectors furthermore women face genderspecific obstacles when starting their ventures the literature relating to women and tourism has been reviewed and expanded it is particularly relevant to examine how gender functions within tourism as the tourism sector is highly gendered with women engaged in feminised positions such as hosts cleaners and cooks however relatively few researchers have examined this subject since swains seminal article which brought attention to how gender often shapes tourisms processes the majority of these studies focus on the economic impacts of seasonality yet nevertheless overlook the influences of seasonality on womens domestic activities researchers from different academic disciplines have discussed the concept of networking particularly those in business economics and sociology however a general conceptual framework for investigating networking is still absent while the studies reviewed here have certainly been informative in terms of revealing the different ties involved in the female business and the structural dimension of networking there is little qualitative information available as to how the entrepreneurs form and develop their networks and what they bring to the entrepreneurial venture through networks therefore there remains an opening for theoretical and empirical research in the field of female entrepreneurs networks methodology this study specifically focuses on female entrepreneurs networking relationships however these relationships do not exist within a vacuum and are part of wider societal structures this emphasis on relationships and broader societal influences led the researcher to dig further into social constructionisms roots considering it a possible philosophical grounding for this study this is because social constructionism revolves around how people interpret what they perceive and how human activity creates that reality the narrative approach is more appropriate for studying subjectivity and identity due to the importance of imagination and human involvement in constructing a story therefore narrative inquiry as a research design can be considered an integral part of producing new knowledge allowing the depth of womens experiences to be better understood in this study the study was conducted in sri lanka because of the researchers familiarity with and exposure to the sri lankan environment therefore female entrepreneurs were selected who are involved in the tourism industry in the southern province where most tourist arrivals occur and where many tourist activities are catered for the purposive sampling method was used to choose study participants various strategies such as extreme or deviant case sampling intensity sampling great diversity typical case sampling and opportunistic sampling were used to select informationrich cases an extreme group or maximum heterogeneity approach produces an initial potential sample and the final selection then had made a combination approach the extreme or deviant case sampling approach emphasises cases rich in information because they are unique and stand out for example the researcher chose hemali as a respondent for this study as she was the best businessperson in the southern region in 2007 and the best businesswoman of 2008 the key informants in this study included and these key informants mainly provided preliminary information about the research participants of the community and the general background of the area in typical case sampling participants were selected with the cooperation of key informants an opportunistic sampling strategy was also used to choose research participants for example the researcher heard about one participant through another respondent during fieldwork the researcher was told that her restaurant was the oldest one in the area and she decided to choose her as a participant in the study the researcher looked for entrepreneurs with different backgrounds and unique stories to tell regarding routes to entrepreneurship the researcher sought to find people coming out of unemployment directly from the university or who had previously been working as an employee one person of particular interest was kumudu who had left the public sector to become an entrepreneur in line with hytti since female tourism entrepreneurs were much debated at the end of the 1990s the researcher sought to include representatives of the new wave‖ of entrepreneurs in this study while most sri lankan entrepreneurs are currently middleaged entrepreneurs of all age groups were needed for this study it was also vital to include women from rural areas as urbanbased women would probably have different circumstances than those from rural areas moreover the sample included both married and single women and women both with and without children to understand the experiences of both parties and the interplay between them concerning traditional practice identity and norms although both sets of women have unique experiences within their social context some aspects of social life are contrasting recognizing these differences and similarities adds to the complexity and quality of the study therefore when selecting respondents for the study the guiding principle was to ensure as much heterogeneity as possible for this study indepth conversational interviews were proposed to tap the female entrepreneurs voices the narrative interview is identified as an unstructured indepth interview with specific features conceptually the idea of narrative interviewing is encouraged by a criticism of the questionresponse outline of most interviews bauer argues that the narrative interview should be conducted through five phases preparation initialisation main narration questioning and concluding talk the researcher was able to complete the 14 interviews which took place in sri lanka from july to november 2016 the interviews were conducted in their place of business and lasted between one and a half hours most of the interviews were carried out during evening sessions except for two interviews when an alternative time was more convenient for the respondents furthermore the second interview took place 1 or 2 months after the first interview therefore it was possible to read and reread the interview transcript data from the first interview which helped identify critical issues contradictions inconsistencies and evasions before going on to the second interview as a new session between july 2016 and november 2016 the researcher visited all female entrepreneurs selected for this study the researcher was able to get firsthand experience of their business place surroundings and networking relationships moreover observation offers an excellent opportunity to obtain detailed and authentic insights into real situations including actions conversations and physical descriptions upon arrival at the research field the researcher tried to develop good social relationships with both the respondents and villagers thematic analysis was used to analyze the collected data there are different styles of performing thematic analysis however many researchers use a fivestep process familiarisation coding generating themes reviewing themes and defining and naming themes considering this the study also followed the five steps process the first step of familiarisation involved transcribing the recorded interviews in detail for the research extracts were reduced where necessary to exclude unnecessary discussions repetition and examples provided by the participants the next step was the codinglabelling process coding means highlighting sections of transcripts and using shorthand labels or codes to describe their content the third stage took in identifying themes usually several codes can be combined into one theme themes are generally broader compared to codes then the researcher tried to make sure that the identified themes had value and accurate representations of the data by reviewing themes the final stage was defining and naming the themes and it involved coming up with a concise and an easily understandable name for each theme results and discussion how do female entrepreneurs form and develop their networksthemes derived from womens narratives how female entrepreneurs form and develop network relationships during their business life cycle has been the focus of interest of many researchers the analyses of the different narratives of female entrepreneurs have produced six themes parents relocation due to seasonality tourisms seasonality affects the distribution of domestic activities and hence the negotiation of related gender roles participants rely not only on help from their immediate family members such as their partners or children but also their parents as many of the respondents parents often live in different cities with their children relocation of domestic activities occurs the parents come to live with the female entrepreneurs for 46 months during the high season to help their children with household and business activities this situation is noticeable for study respondents with small kids my field experience evidenced this i went to meet kumudu on 13th july 2016 and she asked me to wait for her for another few minutes meanwhile her mother talked to me she said she comes to live with her daughter for a few months every high season to help her with domestic and business activities this is an example of temporary migration and the consequent seasonal relocation of domestic activities deepa is a guest house owner in hikkaduwa whose parents relocate to hikkaduwa for the high season to help their daughter with domestic activities such as childcare her parents take on what deepa calls child parking responsibility however they do more than just child parking they carry out various social and domestic activities such as caring for the young children taking the children to schools and classes feeding them cooking cleaning and paying bills on deepas behalf they also provide emotional support for their daughter in the busy and stressful high season these findings correspond with the literature for example lindvert et al highlighted the importance of household and family effects on entrepreneurship in the pakistani culture rather than the economic benefits of entrepreneurship a similar trend in parental relocation from their permanent residence to provide domestic assistance is observed in kumudus story when her mother comes to help out during the high season months relocating from her home during the high season as kumudu says domestic tasks such as cleaning the clothes the food are all responsibilities of my motherwhen she is here the extracts above show the restructuring of social and domestic duties on a seasonal basis caused by tourism an aspect that is absent from most tourism literature while invisible this tourismrelated relocation of domestic duties displays how tourism encourages female entrepreneurs to negotiate their gender roles by effectively offloading these activities onto a relocated parent as the relocated parents are only seasonally available to take over domestic responsibilities they temporarily disrupt negotiations of domestic activities gender roles by taking responsibility for their childrens domestic welfare while this may reduce negotiations of domestic activitiessharing within the family upon their parents departure the female entrepreneurs are left to renegotiate these activities and their related gender roles this adds complexity to how gender roles are transformed as the tourism entrepreneurs can take up productive roles more effectively as they delegate domestic and childcare responsibilities to their parents these findings complied with previous literature for example mcadam et al revealed that womens networks might provide opportunities for mutual support and building confidence which are crucial factors for forming an entrepreneurial identity access to networks beyond local customersa focus on international customers these female entrepreneurs regarded relationships with international customers as part of their everyday lives relationship with customers was further developed through extending reciprocity and hospitality this reciprocity and the appreciation of relationships with international customers such as giftgiving free meals and socialising with customers were evident throughout the narrative interviews and the researchers fieldwork observations such reciprocal behaviour demonstrates these entrepreneurs close relationships with international customers deepa described her experience our guests are primarily repeated customers most guests are british or russian and they call or email to make a reservation they have trust in us and are assured of good service here some call this their second home according to the above extract having repeat customers is a sign of business success in relationships furthermore these women thought about keeping quality relationships to make their international customers happy by providing good service and controlling their negative emotions santos et al found that involvement and emotions are crucial in tourismrelated businesses consequently understanding emotions role can lead to customised emotional tourism services for example tourism marketers can develop promotional activities to match existing and potential tourists the researchers field experience confirmed this i stayed three nights in three different guesthouses all the rooms i stayed in were arranged with care and they are of an excellent standard they maintain reasonable cleanliness sanitation quality food etc they mainly focus on international customers i saw international tourists enjoy homemade local dishes during a homestay all the women confirmed their knowledge of their customers needs desires dislikes and so forth which enabled them to keep intimate relationships with customers one of the respondents told her knowledge about international customers what brittans like is not what americans like russians likes are different from others even though none of the women had participated in intercultural awareness training everyone had adequate knowledge about cultural diversity and understanding of their international customers all the participants were aware of their cultural values beliefs social norms traditions and artefacts that appeal to international customers these womens products and services were in line with cultural values and elements such as art design and materials unique to the country for example chaya stressed that her products are unique to sri lanka and she used such uniqueness to attract customers sri lankas best brand name in batik today… its mine… customers from different countries such as germany sweden france uk and the usa so on come to my shop and they are delighted with my products so the image is significant for repeat customers to target international customers there are souvenir shops with masks puppets shells corals batiks paintings and sri lankan tea jewellery is adapted to western tastes it is not of the vulgar golden type but the simple silver type with beautiful semiprecious stones the images and attitudes toward a destination formed in an individuals mind influence their visit intentions close relationships with locals dramatic changes and development of the rural areas in recent years have introduced a new development model theorised by rae as neoendogenous development based on local development by connecting endogenous material and cultural potential according to the neoendogenous development model social and cultural capital is the main driving force for economic development and the value of local institutions and resources and awareness of business opportunities in the same locality is considered as crucial an example in the sri lankan tourism sector is maintaining healthy relationships with other local businesses such as greengrocers fishmongers beach vendors craft sellers taxis local authorities and the local ngo resulting in better sales opportunities for locals and quality services for tourists these findings complied with baggio and valeri as they found that to survive in the industry entrepreneurs should develop more positive bonds with people even their business rivals hotels and restaurants focus on the cost advantages of using local labour and supplies and guests are motivated to enjoy local activities i also try to help street vendors and small businesses so the fishmonger and the greengrocer are friendly to me tourism business owners maintain good relationships with threewheel drivers when a driver takes a guest to a particular place they usually receive extra payment threewheeler taxis or tuk tuk are vital to sri lankas transport network they operate similar to taxis and are usually a convenient and highly costeffective way to get around many foreigners find it an easy and cheap way to travel short distances during their stay as they have an open roof allowing viewing the surroundings and enjoy the wind blowing by the hotel owner kishani maintains a good relationship with the taxi drivers the hotel allows drivers who want to register at the hotel and is limited to 15 drivers furthermore the hotel provides an identity card and a uniform for drivers with the hotel logo the kishani hotel does not need to interevent to decide in the charges of rides but provides the drivers and their customers a hint about a fair amount as kishani explains this is a perfect method and the hotel has a positive relationship with the threewheel drivers it is suitable for all parties when other threewheel drivers bring in guests i pay them a commission some femaleowned hotels in this study agree with a few threewheel drivers waiting at the hotels for example seethani hotel repainted the vehicles in the same colour to show that the vehicles are only for hotel guests as seethani explains in the beginning it seemed like an effective strategy as the drivers get rides from the hotel guests and the hotel knows with whom their guests were going however after complaints of charging and some other bad experiences of guests with drivers i had to advise my guests not to use these vehicles after that i had to face many problems from threewheel drivers so we always try to keep a good relationship with them seethanis hotel is located in the hikkaduwa town area and there are many threewheel parking areas everywhere therefore the hotel guests will not essentially get a taxi from in front of the hotel though kishani and seethanis hotels initiatives are examples of positive threewheeler regulation they provide reliability and safety with the hotel registration informal recruitment local relationships are essential in recruitment especially for tourismrelated businesses depending on local resources all the women in the study also mentioned that recruitment typically happens from the local community by word of mouth through personal networks such as current staff members fishmongers greengrocers etc for many areas seasonality continues to be an essential aspect of life and they need staff that can fit in around this peak demand indrani relates every year the employees are different because we cannot employ anyone permanently as the business does not function for half the year we speak to the fishmonger the man who sells vegetables or asks around for employees informal recruitment tends to be connected with lowskilled labour in line with this most women in this study actively hired individuals without good prior qualifications or relevant work experience this method eliminated a significant barrier to recruitment in which applicants would otherwise have to invest in capability and gain experience to meet even essential requirements this is critical for recruiting underprivileged individuals from the local community because creating prerequisite qualifications for jobs almost excludes more impoverished people from entree to even the lowest skilled jobs furthermore employing local staff and recruiting informally is typically cheaper for the company than bringing in outsiders which is why sri lankan tourism substantially reduces poverty while jobs in the tourism industry are often considered unskilled and seasonal the importance of income generation to local economies should not be taken lightly this was evidenced by my fieldwork experience as follows many employees are local and very few trained staff members come from areas outside of hikkaduwa a local community labourer is paid around rs1000 daily trained staff members daily pay is 250000300000 one of the most prominent challenges hotels and other tourismrelated businesses faced stemmed from social issues due to local and informal recruitment in general employees from the local area prioritise family and community over job responsibilities challenging employers different expectations about ethical work behaviours such as attendance punctuality and time off moreover most of the staff members of these femaleowned businesses do not usually have prior job experience and learning by doing was used as the only method of training the majority of women take advantage of their socalled natural strengths such as building relationships and creating a culture of collaboration membership in various tourismrelated organisations one of the most effective ways for an entrepreneur to build and develop weak ties is membership in various societies belonging to similar social groups such as membership in professional groups is essential for organisational networking therefore researchers argue that such professional ties involvement is significant to small business female entrepreneurs due to their lack of resources and knowledge in female tourism businesses establishing relationships with professional organisations like the government provides more access to resource acquisition than strong business ties hikkaduwa tourism service providers association is a thriving organisation in hikkaduwa the organisation has 23 parties including threewheel drivers minivan drivers guesthouses tourist shops guides restaurants hotels etc the programme was introduced by the divisional secretarial office because there were numerous problems reported in the sector in hikkaduwa the htspa was established to overcome such issues and ensure the safety of tourists increase the living status and keep sustainable tourism in the area i found that female entrepreneurs were members of various organisations in a few cases for example kumari owns a travel and tour agency and her business is at the developing stage however unlike other women her network consists of professional ties as kumari explained there is also a taasl members night held annually and i attend that because many agents attend that we can make contacts and based on these connections we receive beachside tours and surf riding business opportunities she further explained that by taking membership in several organisations women could develop their business networks and make contacts with different business owners who are ready to share their experiences and expertise more specifically they can learn from each other by providing information and tangible resources needed in the entrepreneurial process participatory learning supports female entrepreneurs in reducing problems in practice developing entrepreneurship and reaching independence this finding is consistent with granovetters weak tie theory the more weak ties business owners have the more connected to the world we are and the more likely we are to receive critical information about ideas and opportunities in time to respond to them attending seminars conferences trade fairs and training programs the network supports entrepreneurs in searching for opportunities generally speaking events such as trade fairs conferences and training programmes bring together individuals with a common interest in technology products or services for a specific industry specifically as a startup company seeking to get the businesss name out there one needs to gain influence through these trade show events to the businesss advantage chaya runs a tourist shop in hikkaduwa it has been 4 years since she started this business and now there is a good demand for her clothes chaya gave her thoughts about attending events such as trade fairs exhibitions conferences and training programmes i am a member of asmte and i participate in their workshops and training programmes i am also registered with the department of textiles and did a course in fashion design it was beneficial to understand how they attract customers use new fashion etc this quotation from chaya shows two critical thoughts first she related new knowledge gained to discuss the importance of participating in training programmes second she understood why the new knowledge and skills were essential by participating in the training programme practicably in this way supported her use of her new knowledge and skills to increase her customer base which was confirmed by the literature for example through collaborative relationships entrepreneurs can share their knowledge resources plans and strategies with others and design new tourism products and services another respondent kumari explained her experience of participation in training in terms of her businesss development after the training programme i introduced a selfservice coffee machine to the restaurant during the training programme we talked about our businesses and about a book we have read a movie we have watched so everybody can learn from each other in line with the community of practice theory kumaris idea makes known the mutual exchange of participation in a community of practice she describes her approach being changed even as she through her participation changed the community in other words participation changes the community as the community changes the participant attending social gatherings another way of evolving the network is by attending social gatherings organised by various communities forums neighborhoods etc the most common approach adopted by female entrepreneurs is attending religious and cultural events organised by people of the same ethnicity contacts through social gatherings have always played an influential role in business success and those with an extensive network of contacts are usually exposed to more opportunities and better leads when people attend a live event such as a social gathering they have access to other attendees therefore these events are an excellent opportunity to connect share information learn about peers and the sector etc networking is not limited to entrepreneurs during social gatherings and these informal connections are often invaluable anoma related her experiences and how she tries to contact different people in social gatherings i look at every social gathering as an opportunity to find out how other people think what they do for a living and what they know about me furthermore if i can assist them i like to do so in line with wengers cop theory anomas explanation refers to the importance of being mutually engaged in activities therefore she is happy to share information and resources and be responsible for others another respondent kishani revealed that relationships with different types of people in her daily routine influence her businesss smooth running as she explained i also try to help street vendors and small businesses so the fishmonger and the greengrocer are friendly to me the people in galwala in galle are thugs but they too are friendly with me i visit them and participate in their weddings and funerals because we need people from all walks of life without which it would be difficult to run this business this quote from kishani illustrates the idea of emphasising the importance of informal networking which has been invaluable to running her business by engaging in casual conversation with others she learns a lot about people and who they are she finds informal networking to be a much more effective way of running the business and mutually beneficial to a relationship furthermore it illustrates how networking can arise anywhere and how one does not need to be in a professional setting to network and meet people who will support your business activities and vice versa these findings are in line with previous research conducted on voluntary associations and social capital conclusion this article provides indepth information about how female entrepreneurs form and develop their networks focusing on the structural dimensions of networking and thus it contributes knowledge to the extant literature as highlighted in the literature many researchers focused on quantifying the network size frequency and density yet little attention has been paid to analysing network actors actual contribution and involvement in femaleowned businesses therefore the findings of this study are anticipated to fill a further gap in the literature another major theoretical contribution lies in this research connecting female entrepreneurship and networking while researching the tourism sector findings suggest that in sri lanka small female businesses depend on more informal recruitment and they have strong relationships with local communities but they focus on customers beyond the locals female tourism entrepreneurs face unique challenges such as seasonality and 14h workdays affecting how they negotiate the activities required to perform daily and which intergenerationally include household duties identifying a liminal gender renegotiation period at the end and the beginning of the season stimulating seasonal gender role negotiations adds an exciting dimension to the perceived impacts of seasonality while seasonality has been examined from various directions as a structural cause of disruption to economic processes very little has been written on the effects of seasonality on womens domestic tasks by revealing how seasonality acts on the relationship between entrepreneurship and gender roles this study expands the knowledge on tourism seasonalitys socioeconomic impacts furthermore this study reveals that female tourism entrepreneurs parents temporarily move location to support their children in their domestic tasks while generally invisible within the tourism literature this tourisminduced seasonal relocation acts as a rearrangement of household responsibilities as female entrepreneurs offload such tasks onto relocated parents resulting in a temporary disruption of gendered negotiations surrounding domestic duties in this setting while many researchers from developed countries focus on the economic benefits of entrepreneurship this study offers an understanding of how entrepreneurship could be used as a tool for flexibility and freedom it also helps open eyes to more profound implications for social outcomes from networking relationships than economic ones the studys findings communicate to entrepreneurs policymakers and supporting organisations over the past 20 years small business development has been the central area of donor support for developing economies this traditional support system has focused on providing more software and hardware support for small enterprises however they should focus their consideration and programmes on providing increased resources and more facilities and networking input therefore networking is one of the answers even though it is not a magical solution because through established network relationships businesses can gain access to external resources and encouragement and influence it was identified in the study that the interactive effects of actors of networks and resources stimulate the development of businesses but not the resources alone therefore entrepreneurial development programmes should extend support to female entrepreneurs to establish and develop effective relationships with external actors thus several collective organisations of entrepreneurial women could help promote entrepreneurship among women and thereby empower them to join the economic mainstream leading to the social development of sri lanka a few limitations are linked with this study some of which originate in constraints on time and money some of these while limitations provide paths for future research the data collected for this study depended on the responses from one party and can be viewed as somewhat subjective preferably a second party would validate at least part of the information collected about the entrepreneurs data collected from these womens husbands other family members or employees could have been used to confirm the businesss information if more time and resources had been available moreover this study focuses on female entrepreneurs networking experience in sri lanka and there are various conclusions from the study even though some researchers suppose their findings of a single country are generalisable to other countries these findings cannot be generalised as a global phenomenon similarly some of the aspects of this research are not necessarily globally applicable but they may be known in patriarchal societies abbreviations

research focusing on female entrepreneurs in other sociocultural contexts is relatively new and limited in number arasti et al 2021kirkwood 2012roomi et al 2009 while gender is a heavily researched area however on the other hand female entrepreneurship and networking as one are rarely considered when examining the tourism phenomena figueroadomecq et al 2015valeri katsoni 2021 this study contributes toward filling this gap by focusing on the networking experiences of female entrepreneurs in small businesses in the tourism sector in sri lanka furthermore this research demonstrates that female entrepreneurs in sri lanka face different constraints

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background the omission of groups of lower socioeconomic status from public health and medical research has been observed for some time regardless of type of research study 1 in most western developed countries white middle class highly educated males tend to be overrepresented in health and medical research and people from socially disadvantaged groups underrepresented 12 failure to obtain medical research data which accurately reflects the breadth of the whole population poses a number of drawbacks including threats to external validity and ability to generalise 3 denying excluded groups from any health benefits of trial participation 4 inability to check the safety of health innovations with subgroups in the population 5 and failing to identify groups that have the highest burden of illness and developing an understanding of why differences exist 6 researchers continue to struggle to access engage and retain participants from socially disadvantaged groups 7 resulting in labels such as hardtoreach or hidden according to sydors 8 definition that hard to reach populations are difficult for researchers to access and lambert and wiebels 9 definition of hidden populations as those who are disadvantaged and disenfranchised the homeless and transient chronically mentally ill high school dropouts criminal offenders prostitutes juvenile delinquents gang members runaways and other street people socially disadvantaged groups are difficult for researchers to access costefficiently in large numbers necessary for statistically powerful study designs there are many reasons why socially disadvantaged groups are not included in health and medical research understanding these factors is necessary for developing strategies to increase the level of involvement and participation in health and medical research for disadvantaged groups this study aims to review the literature regarding the barriers to sampling recruitment participation and retention of members of socially disadvantaged groups in health research and the strategies for overcoming the barriers that may help increase the amount of health research conducted with socially disadvantaged groups methods search strategy searches of electronic databases medline psychinfo embase social science index via web of knowledge and cinhal were conducted for english language articles published up to may 2013 a widenet search strategy involving combinations of the following keywords was initially conducted to capture as broad a sample of studies as possible difficult to reach or hard to reach or social disadvantage and health research an iterative process was used where more general searches were conducted initially with papers identified informing subsequent targeted searches a general internet search with google scholar also assisted in the search for grey literature free text searching was implemented using the following key words hardtoreach difficulttoreach and disadvantaged with health and health research in addition manual checks of the reference lists of retrieved articles and citation searches were conducted selection criteria articles were included if they reported attempts to increase socially disadvantaged group participation in research or barriers to conducting research with socially disadvantaged groups socially disadvantaged groups were defined as socially culturally or financially disadvantaged compared to the majority of society implying individual environmental or social restrictions to their opportunities to participate in health research 8 9 10 in order to capture a broad representation of evidence qualitative quantitative mixed methods case studies and literature reviews were included only studies that focused on healthrelated research were included studies were excluded if they described improving access for socially disadvantaged groups to health services rather than health research were primary articles which had been cited in the previous literature reviews focused on age or gender groups without explicitly stating that the group was socially disadvantaged editorials and commentaries were also excluded data extraction articles obtained from the electronic database searches were assessed by one reviewer in two phases 1 title and abstract review and if it appeared relevant 2 full text review together with a second reviewer full text review of articles obtained was conducted uncertainty was resolved through consultation with the other reviewer two reviewers extracted data on country descriptors of the studys target sample group variables measured study design and key findings on a the barriers to participation in health research and b strategies to improve participation were extracted and summarised the results of the included studies were further categorised according to five stages of a research study where representativeness may be threatened 1 developing a sampling frame 2 recruitment and gaining consent 3 data collection and measurement 4 intervention delivery and uptake and 5 retention and attrition these stages were imposed by the study authors prior to data extraction assessment of risk of bias given the considerable heterogeneity of study types a systematic scoring system for evaluating the methodological characteristics of individual studies or risk of bias was not applied instead a graded system of levels of evidence based on study design alone was used a number of hierarchies of evidence exist 11 12 13 and were adapted for this study results the electronic searches yielded 8497 potential articles and 36 articles were identified using additional search strategies following removal of duplicates eligibility screening yielded 116 primary source papers from 115 studies that met inclusion criteria the majority of the included studies were based on research conducted in the united states of america 23 papers describing 22 studies were conducted in the united kingdom 1415 nine in australia 113 114 115 116 117 118 119 120 121 four in canada 122 123 124 125 two in europe one in new zealand 128 and one usled study based in mexico 129 table 2 summarises the socially disadvantaged groups targeted in the included studies african american and diverse ethnic and racial groups were the most studied groups the vast majority of articles describing strategies for improving representativeness were nonexperimental descriptive surveys qualitative studies or case studies only 7 articles reported the results of randomised controlled trials in addition 31 previous reviews of related literature were identified and summarised in table 3 including two papers which presented both original data as well as a literature review 1434 developing a sampling frame barriers of the 31 literature reviews 10 focused on sampling 34 136 137 138 149 150 151 152 153 154 and 33 primary source articles on sampling issues were found 32 33 34 38444751535457 table 1 summary of the 116 included studies study designs and level of evidence level of evidence study type n of studies reference good randomised controlled trial 9 2324363742438890106 fair nonrct comparison of strategies or groups 14 1725415961627983104109110116126128 poor descriptive study 48 141516181920212226273033353839404445 464749505153545865666771757677 818485 879195969799112113117119120125129 poor qualitative study 16 2932606468727386899294101108122124127 poor case studies without data 28 2831344852 55 56 57 6369747880829398100102103105107111114115118121123 descriptive studies are observational with no comparisons made but data is reported figure 1 flow chart of included studies footnote a did not report barriers or strategies to improve participation not socially disadvantaged group focus on health service participation rather than health research participation not english language b focus on health service participation rather than health research participation not socially disadvantaged group 60 61 62 6774 77 78 79 8184919597 102 103 104 113116118122126128 random population samples are often insufficient to accumulate large enough samples of hardtoreach groups this barrier was reported across study types from large scale population health surveys to intervention trials some studies identified difficulties sampling groups defined as hidden populations consisting mostly of people who do not want to be identified such as people who use illegal substances or selfidentified groups such as homosexual people others described difficulties sampling groups with low numbers in the population such as indigenous people as a result population based probability sampling tends to be a time and cost inefficient strategy for sampling socially disadvantaged groups strategies to improve sampling nonprobability sampling a number of alternatives to random probability sampling were described including snowballsocial network or respondentdriven recruitment venue based timelocation sampling targeted sampling capturerecapture adaptive sampling and oversampling of low prevalence population subgroups 3334385357798495102104113126129 except for oversampling methods for low prevalence populations 91149 all of the other sampling strategies require formative research to identify venues times and contact persons to develop a targeted sampling frame for the group of interest which may impose significant time and cost to the research some strategies such as snowball and respondentdriven sampling involve referral chains of sampling selection bias and gatekeeper bias which limit validity of the sample are the primary limitations of these strategies while these issues may not be problematic for studies which do not require representativeness for generalizability such as qualitative research they do have limited use in quantitative research sampling through community organisations one option for creating a sampling frame for specific socially disadvantaged groups is to collaborate with community organisations with access to those groups and to draw a convenience sample through that organisation 444754 60 61 62 6774103116118122128136 benoit et al 122 variously defined community group as any group with high access to the target population and partnerships have taken three main forms a the community group helping researchers gain access to an otherwise hardtoreach group b a reciprocal relationship in which community members and researchers have knowledge and learn from the other and c communityinitiated research projects that seek academic partnerships and use the outcomes to direct policy and program delivery while this form of convenience sampling may not be representative of the general target group it presents pragmatic advantages for sampling large numbers of members of socially disadvantaged groups african american 19 19252831363741434447505758 70 71 72 73 7581 substance abusers 14 23243334 65 66 67 798082839598126 general vulnerable minority disadvantaged 11 30324851527297788489120 indigenous people 8 113 114 115 117118121125128 low income disadvantaged area 7 54649699106108119 hiv 7 35646776100124129 low income rural 7 49 68 69 70 71 7488 gay lesbian bisexual and transgender 4 385183102 low literacy group 4 45488687 homeless people 4 27405995 high risk youth 3 395566 survivors of violence 3 172653 sex workers 1 122 mental illness 1 40 people with a disability 1 116 study may appear in more than one category if more than one population group was investigated advantages and disadvantages of each strategy discussed combinations of sampling strategies fifteen studies described the use of a combination of sampling strategies 2 targeted sampling targeted sampling which requires ethnographic data provides important qualitative information respondent driven sampling venuebased sampling allowed a systematic recruitment of participants and produced probability samples but only of the visits to the venues included in the sample respondent driven sampling based on social networks permitted calculation of population estimates • disproportionate stratified sampling • twophase sampling • use of multiple frames • multiplicity sampling • location sampling • an active commitment to recruiting african american subjects • community outreach programs and advertisements • involvement of local churches and community organizations • publicity campaigns directed at african americans • participant logistics such as convenient testing times transport convenient location • use of incentives • use of african american role models • flexibility and willingness to change protocol • use of lay health workers • door to door canvassing • phone recruitment significantly better than mail or postcard communitybased strategies • community engagement produced mixed recruitment results with locals as recruiters important success factor incentives • only 1 trial of incentives found no effect on retention wallace bartlett 158 narrative review with about 38 studies african american and hispanic girls and women recruitment and retention recruitment recommended using all of the strategies outlined comparisons of strategies a number of studies provided comparisons of different sampling strategies such as respondent driven sampling compared with targeted sampling finding that in most cases these sampling approaches produced similar sample size and representativeness however there were differences in costs platt et al 126 compared respondent driven sampling with snowball sampling to reach high risk hiv participants and found that although snowball sampling was more costly it resulted in greater participant numbers keyzer et al 62 found that direct mail community outreach and recruitment through a health education council were the most costeffective strategies for recruiting minority groups while use of mass media and advertising was a highcost lowyield strategy in new zealand mhurchu et al 128 5 reasons provided for low response rates in research with socially disadvantaged groups included mistrust in research or researchers particularly amongst african americans and indigenous populations who had a history of being mistreated in medical research fear of authority and perceptions that participation presented no personal benefit to them or their community and may cause potential harm stigma mistreatment or exploitation similarly members of some groups may fail to participate in research out of fear of being publically exposed particularly if they engaged in illegal behaviours such as prostitution gambling or illicit drug use or are socially stigmatised such as people with hiv or aids or people who are glbt one review however found that willingness to participate in research was as high in table 4 summary of the results from sampling studies included in the review barriers strategies difficult to locate or reach and access groups • snowballsocial network or respondentdriven recruitment 335760627984 102 103 104 116118126129 frequent change of address or selfidentifying results in no sampling frame • timespace sampling 38104113 • targeted sampling 3479 • capturerecapture 95 • adaptive sampling 53 • partnerships with community groups 3240444754 60 61 62 6774103116118122128 low prevalence in population • combination of various data sources as a novel methodology to avoid sampling 6297 or supplementing with additional data 4447546067103113122128 • statistical analysis techniques to population survey data for lowfrequency samples 91 • internet samples 51 table 5 summary of the results from recruitment studies included in the review barriers strategies lack of trust in researchresearch team or uncertainty regarding how survey results will be used • communitydriven research 4456707175114 and community partnerships 1828757778809394100101113115 fear of authority • peer or known recruiters 212840748296113115105121123124 perceived harms of research • sensitive wording study conversation and dialogue instead of investigation research and interview 26476092 mistreatment and exploitation • use of handwritten envelopes 106 no benefits for participation • enlisting community leaders 60113114115127 • commitment to give back to the community through sustainable interventions 3194114115 or reciprocal benefits 6474101 or if not resourced to provide intervention provide links to services 118 or minimal intervention controls 44 • shared data ownership and publication 114118 • gifts with project logo 1830 92 93 94 118127 and incentives 4247119123 • thank you and award ceremonies and project feedback 114118 • emphasising potential benefits 74 • improved communication and culturally relevant education materials 32 lack of educationawareness re research or health promotionlow health literacy difficulties understanding consent and what the study is about • utilising appropriate media 18254156658587119 mass media 61627281 or social marketing strategies 37477283 • provision of participant feedback regarding the research outcomes 30115 • public information sessions 47116 • simplified consent formslarge font plain language shorter sentences in respondents language ensure translation makes sense wide margins shorter paragraphs 4586114 • bilingual recruiters and materials 18568592104112 cultural beliefs gender rolesage related issues • cultural competence skills of research teamwell trained research staff 1622305663101104118 • culturally targeted media 4172113115 • mindful different cultures require different strategies 164363679394103118125 • recruitment strategies adapted to local conditions for a communityspecific approach 1663858693113125 gatekeepers doctors or nurses who do not approach minority participants high turnover of staff limits relationships • work with gatekeepers 1415100103123 employ locals as staff 225593113118 doctor poor communication methods • ensure appropriate authorities are consulted 113114 rigid exclusive eligibility criteria • patient education materials 32 • financial incentives for recruitment partners to employ support staff to recruit 3244143125 • flexible eligibility criteria 3550 stigmafear of exposure • online focus group and interview research 5152 or video recruitment 46 • community advisory group 2847100113118 low response rates in general • multiple contact attempts 40668199 • tollfree number 6170 or followup a mail survey with a telephone survey of nonresponders 106 • through doctorshealth services 8593103123 • outreachhome visits 212599 • text messaging 65 • incentives 18304042 43 70819294123127 • recruitment letters an advance letter 36 or culturally framed letter 43 racial and ethnic minority groups as it was in caucasian participants 146 suggesting that factors other than participant attitudes or beliefs play a role in limiting health research participation other barriers to the recruitment of vulnerable populations included cultural beliefs prohibiting participation age and gender issues whereby in some cultures discussing health issues is viewed as sensitive particularly if female elderly or young and a lack of awareness of health research or education about participation in health research low literacy affecting ability to provide informed consent was also described as a barrier to recruitment gatekeepers who restrict access to health research have been identified by some studies as a barrier for research participation some health professionals who have the opportunity to encourage research participation have been found to fail to do so due to paternalistic beliefs that people in lower socioeconomic groups dont have the time interest or ability to participate or have poor communication skills participant lack of understanding of the research information process or significance was reported as barriers to gaining consent in one case participants not understanding the need for random sampling was reported as a barrier to gaining consent since potential participants believed that those who needed the research should be approached not randomly sampled 113 other papers highlighted the restrictive nature of some eligibility criteria which excluded socially disadvantaged groups particularly in clinical trials 141550 improving response rates communityresearch partnerships in order to address some of the recruitment barriers relating to mistrust or fear of research and gatekeepers impeding recruitment 25 studies 1821223140555660637077788082939496100101105 113 114 115 124125 and eight reviews 131135136141144145 suggested that community groups be involved in the research and recruitment process this may be particularly effective for communities that have hierarchical structures such as australian aboriginal communities who look to their elders to provide leadership some reports have suggested that engagement of local peer or known community members as recruiters will increase trust and response rates 2140558296105121123124 similarly the use of community advisory groups is likely to be beneficial and increase the perception that the research is communitydriven and responsive 2847100113118135 germino et al 28 used a comprehensive community based approach to recruit a representative sample of african american cancer survivors the approach was designed to address recruitment barriers of mistrust and enhance familiarity they engaged a number of community groups for promotion and education about the research including cultural brokers to liaise between participants and researchers they reported high recruitment and retention rates these community based strategies offer shared ownership of the data and publications produced as a result of the research ensuring that the research will provide either sustainable programs beyond the life of the research project or links to services and resources providing gifts financial incentives or thank you awards and ceremonies which include feedback to the community about the outcomes of the research were also presented as important components of communitybased recruitment 1830 92 93 94 127158 in a review of recruitment strategies for clinical trials with minority groups by uybico et al 141 community organisationbased recruitment was found to be the least effective form when compared to social marketing use of health services and referral based recruitment similarly martin et al 21 found that despite extensive community consultation and use of community based facilities and bilingual recruitment materials low recruitment of mexican american participants persisted recruitment increased once local spanish speaking workers were engaged to conduct outreach recruitment use of media and social marketing eleven studies reported the use of media and social marketing techniques tailored to the target audience 18454665727381858699119 however these studies fail to provide a guide as to which medium would be most effective with different target groups and instead suggest that formative research should determine the most appropriate strategy uybico et als 141 review found social marketing to be the most effective recruitment strategy for minority groups into clinical trials compared with table 5 summary of the results from recruitment studies included in the review • two stage recruitment 1 to a low commitment survey then 2 to the trial 83 • assistance with transport or child care 3073 • shorter surveys 106 • develop a registry with interested people 25 indicates good evidence from randomised controlled trial health provider recruitment and community organisationbased recruitment a key component which is common across studies recommending the use of different recruitment channels is the need for the recruitment channel to be culturally and linguistically appropriate 1645718692 this can address both barriers of lack of awareness of health research and cultural barriers studies also highlight the need to educate research staff to ensure cultural competencies and understanding which are likely to enhance response rates 2230 strategies to encourage gatekeeper support strategies for addressing the barrier of gatekeepers include employing gatekeepers as project recruitment officers and involving them in the research 2293100113118 ensuring that community authorities are informed about the research and adequately consulted 113114 and paying health professionals through financial incentives to assist with recruitment 125143 loftin et al 71 reported slow recruitment and low response rates in a study using primary health care provider identification and recruitment of african americans into diabetes research one review suggested developing patient materials that can be distributed directly to potential participants of clinical trials thus overcoming the barriers of clinicians being too busy to recruit or having poor communication skills 143 mathy et al 51 compared an internet derived sample with a gallup poll sample of the us general population they found the samples equivalent in educational distribution and geographical location and the internet sample reached more representatives of lower income and ethnic diversity comparison studies four of the nine rcts examined the effectiveness of recruitment strategies 364243106 as did three nonrct comparison studies 417583 in a rct by satia et al 43 potential african american participants were randomly assigned to receive either generic or culturally sensitive invitation letters within each letter group participants were randomly assigned to receive a small incentive while the overall response rate was low it was significantly higher for those receiving the incentive compared with those not receiving an incentive there was no difference in response rates between those receiving the generic invitation letter and the culturally sensitive letter 43 maxwell et al 42 trialled three incentive conditions to increase response rates to a baseline survey amongst racially diverse groups no differences were found and response rates were low another rct assessed whether an advance letter mailed out two weeks prior to a mailed survey would enhance response rates among african american participants compared with white american participants 36 statistically significant differences were found for white american participants only illustrating how a strategy can potentially contribute to disparities in a rct of handwritten envelopes compared with printed envelopes to increase survey response rates in a socioeconomically disadvantaged area choudhury et al 106 found that the handwritten envelopes resulted in slightly but not significantly higher response rate using debriefing questionnaires to glean interviewer experiences of recruiting subjects using three different methods mclean campbell 109 found that local advertisements and use of media recruited the highest number of white english participants interpersonal contacts increased recruitment of pakistanikashmiri subjects and organisational contacts recruited the most africancaribbean subjects all approaches included financial incentives for participation oakley et al 112 compared the cost of using interpreters to increase recruitment of nonenglish speaking women costs per person recruited were higher for women who needed an interpreter compared with for those who did not one unique study 25 sought to develop an african american health research registry for easier future recruitment and engagement with research the study compared direct recruitment methods with indirect methods the study concluded that all strategies were needed to recruit a representative sample into the registry because some strategies were more successful with subgroups other strategies a number of reports have suggested that study inclusion criteria need to be broadened in order to increase the representativeness of samples particularly in relation to comorbidities 3550 adamscampbell 50 suggested that investigators incorporate examination of comorbidities into clinical trial study protocols a novel suggestion to tackle the barrier of uncertainty about random sampling is to include others within the participants immediate family or community in data collection 113135 but only to use the data from the individual that was randomly sampled clearly this approach has ethical resource and cost implications sutherland et al 26 described a range of personalised strategies to aid recruitment of abused rural women into sensitive research about the risk of sexually transmitted disease they found that personalised approaches like knitting together and changing terminology to promote trusting relationships boosted recruitment rates 26 data collection and measurement barriers in total 29 studies 45484952 54 55 56 59606368748590 96 97 98 100105106110111 113 114 115 117118120124 and seven reviews 133 134 135 136 137 138 140 explored barriers and solutions for collecting research data with participants from socially disadvantaged groups the need for complete and representative data from health research studies is common across study types but is particularly important in surveys language lack of education and low literacy barriers may prohibit the collection of certain types of data such as selfadministered survey data similarly a barrier which is specific to telephonebased data collection is the lack of landline telephones amongst disadvantaged groups limiting their inclusion in epidemiological and populationbased research shebl et al 49 for example found significant differences between those with or without landline telephones in raceethnicity health care access insurance coverage and several types of health behaviours including smoking status and cancer screening behaviours the resulting bias suggests that populationwide surveys utilising only landline telephone surveying techniques are not providing accurate estimates of health behaviours finally suspicion regarding the use of the data collected and mistrust of researchers were identified as barriers improving data collection and measurement methods inclusive language and methods one of the most common strategies to improve inclusion of linguistically diverse or low literacy groups in health research is to simplify the reading age of the study materials or to translate materials into other more common languages 456396113 and use bilingual research assistants 458590100111 a number of studies highlighted the need for culturally trained and skilled fieldworkers 56111140 or employing locals or peers to conduct field work 55749698105115118 use of insiders offers the added advantage of addressing any researcher mistrust or suspicion 105 as well as building the capacity of the community or organisation in conducting research one method of data collection called photovoice allows participants to use photos and pictures to respond to spoken questions or scenarios and to tell a story 133 photovoice has been used with australian aboriginal communities where the telling of stories is often through paintings and art its use is limited as an exploratory qualitative tool and does not provide largescale quantitative data flexible data collection methods in order to address barriers to socially disadvantaged groups participating in telephone surveys a number of studies have outlined the need for flexibility and tailoring of data collection methods to participant circumstances 60113114 if participants cannot be reached by telephone data collection telephone surveys could be supplemented by facetoface door knock interviews 49 or online surveys 52 allison et al 110 caution that supplementing postal questionnaires with face to face interviews may not produce responses with equivalence as comparisons of these two modes of survey delivery resulted in very low kappa agreement scores for some items working with australian aboriginal communities couzos et al 114 proposed a communitycontrolled research process including data collection and management which was flexible and involved locals employed to administer the research protocol table 6 summary of the results from data collection studies included in the review barriers strategies language or literacy problems • measures in other languages or bilingual interviewers 4563859096100111113 • use of multimedia 48106 or computer data collection 4859120 • avoid selfadministered surveys 117 use of objective data 97117 • short surveys 106 lack of landline telephone or highly mobile population • mailed survey instead of telephone 90 • supplement telephone with facetoface surveys 49110 • online surveying 525468 • use of objective data instead of selfreport 97117 • flexible data collection 60113114 mistrust of researchers and the use of the data • culturally trained interviewers 56111 or locals 55749698105115118124 • need to pilot test measures 100114115 indicates good evidence from randomised controlled trial thomas et al 117 has suggested that selfadministered surveys should be avoided if possible with disadvantaged groups where it is difficult to collect data directly from the individual and instead communitywide objective data be used these authors give the example of tobacco and alcohol sales data from australian aboriginal communities this measure is only a proxy to behavioural measures and provides limited data about how the tobacco or alcohol might have been used and by whom however in some cases the objective data could be supplemented with smaller targeted qualitative research using methods such as photovoice to gain a more complete set of information about a health concern or health behaviour similarly dowrick et al 97 suggest using secondary data sources supplemented with small qualitative data collection as measurement tools in studies assessing health service needs with socially disadvantaged groups use of technology to gather data five studies suggested using the internet or other technologybased strategies to collect data from socially disadvantaged groups such as those living in rural areas 48525468120 hahn and cella 48 described the acceptability of a touchscreen computer delivered health survey with patients categorised with high or low literacy ability and found that acceptability was high across both groups almost all patients felt the touchscreen survey was easy or very easy to use pilot testing measures hing et al 115 and couzos et al 114 highlight the importance of involving local community partners in the development of research protocols and materials when working with australian indigenous communities and the importance of extensive pilot testing of materials 100 comparison studies one randomised trial of survey methods was included in the review 90 in this trial ngometzer et al 90 compared data quality following a mailed health survey compared to one delivered by telephone with asian american participants the surveys were provided in both english and the target language no differences in reliability or nonresponse bias were found the telephone interview resulted in a significantly higher response rate and fewer missing items 90 in a preand postcomparison study choudhury et al 106 found that shortening a 12page questionnaire to two pages significantly increased the response rate in a study with respondents from economically deprived multicultural areas for assessing substance abuse alemagno et al 59 compared a telephonebased interactive voice response system to a face to face interview and found high reliability and validity of the computer assisted telephone method the computerised voice telephone system offered participants anonymity 59 intervention delivery and uptake barriers thirty six articles 19202729313537405255565864 67 68 69 717377788082858788105107108114118122124 and five reviews 130 131 132 148157 considered intervention fidelity concerns about randomisation that some members of the community will not receive what may be a beneficial intervention has threatened the implementation of intervention trials in some communities 40148 in some cases the concern has been about the loss of control over deciding who receives an intervention and who does not 132 these threats could result in contamination if intervention group participants or those conducting the randomisation offer the intervention to control group participants equally of concern are interventions that do not align with the perceived needs or priorities of the target group or interventions which are not acceptable feasible and culturally appropriate to community values and beliefs 7180 improving intervention participation and fidelity alternative methodologies and study designs alternative study designs to the classic rct have been proposed that may be more acceptable 27131 such as multiple baseline designs stepped wedge designs and waitlist control groups where the intervention is delivered to all groups at different times 29 yancey 148 outlines other designs whereby the control group either receive an alternative treatment or they receive the intervention after the trial is over similarly hough et al 40 randomised homeless people to four conditions each providing interventions that were greater than the services participants were receiving before the study yancey et al 148 and woods et al 73 also highlight the importance of educating participants of the need for randomisation to enhance understanding and ensuring that the control group receive at the very least usual care and that they are not having health care denied them communityparticipant involvement in intervention design seventeen studies 2731355667707174778085107108113114118122 suggested community involvement in the design of health interventions as a means of avoiding the barrier of culturally inappropriate interventions while the opportunity to design pharmacological and clinical medical interventions together with potential participants is very limited it is a strategy that is particularly relevant to public health or behavioural interventions involving the target group in intervention design for public health interventions and careful inclusive use of formative research to ensure that both the content and delivery of the intervention is acceptable to the target group can increase likelihood of uptake 7080113114118 to design culturally appropriate smoking cessation interventions for american indian communities fu et al 29 conducted focus groups participants reported that the following features of the intervention were important to them programs led by american indians opportunity to link with other american indians interested in quitting free nicotine replacement therapy incentives and culturally specific program components such as american indian images education on traditional tobacco use messages that value family and include narratives or stories 29 ammerman et al 31 described the development of a culturally appropriate intervention which was based on theories of sustainability and diffusion this is viewed as an attempt to give back to participating communities through sustainable interventions which are adopted beyond the life of the research 3178114 and which build capacity within communities to address the health issue independently of the research 56124 modifying interventions implemented in general populations so they are better tailored to disadvantaged groups such as low literacy or rural groups 195258686987130157 has been suggested other studies emphasise the benefits of including community members locals or peers as intervention delivery agents for improving compliance to the intervention 20555882105108124157 for example hughes et al 82 outlines a peer educator participantdriven intervention for injecting drug users as an ethical public health model similarly rothschild et al 20 employed bilingual mexican american community health workers from local neighbourhoods as culturally competent peer interventionists in their trial of a diabetes management intervention for mexican americans and reported high intervention participation and fidelity comparison studies two rcts of intervention strategies tailored for disadvantaged groups were included in the review in a blinded randomised trial nicholson et al 37 compared emotional and behavioural responses to four versions of an information intervention provided to africaamerican communities regarding colorectal cancer screening participants exposed to the two versions highlighting disparities framed in a negative way reported more negative emotional reactions in contrast the progress framing elicited more positive responses and potential participants were more likely to agree to be screened the results of this trial suggest that the way in which health information is presented can influence attitudes and intentions with reports about progress yielding a more positive effect on intention the authors note that this is especially important among those with high levels of medical mistrust befort et al 88 compared the effectiveness of group versus oneonone telephone counselling for 34 women in hardtoreach rural areas compliance with the 24week program was similar between groups although they did report a significant improvement in weight loss with those in the groupbased intervention losing more than those receiving individual counselling befort et al 88 also found the group program to be costeffective table 7 summary of the results from intervention fidelity studies included in the review barriers strategies concerns regarding randomisation ie not getting treatment loss of control mistrust • ensuring minimal standard of care for control group or minimal intervention for controls 2940 or alternatives to randomised controlled trials 27 • use trusted sources of information 87 • participant education regarding the benefits of randomisation 73 • including peers and locals in intervention delivery 20555882105108124 health intervention not culturally appropriate • community involvement in development action research method or cultural immersion 272931355667707174778085107108113114118122 • culturally tailored programs 19295258 68 69 70 8588118 distance for delivery of intervention • groupdelivered telephone intervention 88 negative framing of health information emphasis on disparities • positive and progress emphasised in health information 37 indicates good evidence from randomised controlled trial other in a systematic review of diabetes care interventions for socially disadvantaged groups glazier et al 157 noted that the following factors improved both health outcomes and participation with the intervention oneonone interventions focussing on behaviourrelated tasks providing feedback and high intensity interventions delivered over a long duration the review found that interventions which used mainly didactic teaching and focussed on diabetes knowledge were the least successful attrition and retention barriers twenty six studies 16 17 18 20 22 23 24 30353940546566 70 71 72 73 74 75 76 80818596123 and six reviews 135139145147148158 examined barriers to retaining participants in research and strategies for maximising retention rates the most common barrier reported related to followup data collection was difficulty maintaining participant contact challenges to maintaining contact included the transient nature of the lives of those in many socioeconomically disadvantaged groups with phone numbers and addresses changing frequently practical barriers often related to their socially disadvantaged status such as transport difficulties inability to take time away from work to participate lack of childcare or simply forgetting about the research which is competing with other priorities of daily living 73 improving retention rates incentives and gifts the most commonly trialled strategy for maintaining involvement of participants throughout a research project was the use of incentives and gifts 18 22 23 24 303940 71 72 73 768081123158 cash incentives have been found to be more effective than noncash incentives 23 however the use of study branding or logos on noncash gifts has been reported to be effective in case studies at keeping participants involved 74 in a study with young latino women lindenberg et al 80 found that financial cash incentives were considered unacceptable and that vouchers for grocery or department stores were preferred other studies attempted to maintain contact and participations with other gifts such as clothing birthday and other holiday cards mugs and personalised followup letters 717380 coffee food or drinks 40 if travel is required woods et al 73 found that focus group participants suggested transport vouchers and bus tokens as incentives to return to the study 7173 some researchers have noted that these little gifts build trust and relationships between participants and researchers 4070 another two studies of patients receiving treatment for substance abuse found that cash payments did not lead to use of the incentive to purchase illicit drugs and participants reported no perception of coercion 2324 in fact the studies found high participant satisfaction with the study better followup rates and reduced tracking efforts multiple tracking reminders and contact procedures keeping in regular contact with participants has been reported as an effective method of lowering attrition ensuring that researchers have multiple forms of contact for each participant has been reported to be essential for maintaining contact with participants from vulnerable groups who may be highly mobile 17202230394054758185 as well as having contact details of significant others 206676 using a participantcentred approach during these multiple contacts such as personalised telephone calls rather than generic reminder letters enhances retention 182073123 in a small pilot study with 48 methamphetamine injectors maher et al 65 found mobile phone text messaging was a successful method of reaching participants throughout the study participants reported that the text messaging was acceptable and there were no differences in the demographics between those who were retained and those who dropped out meyers et al 66 provide a detailed analysis of the tracking strategies they used to obtain extremely high retention rates with substanceabusing youth the authors described enhanced tracking efforts such as obtaining various contact details during their substance abuse treatment and post treatment use of a locator form which recorded the contact details of family members agencies they use and community locations they frequent small participant incentives were offered for followup and approximately 40 of participants required six or more contacts in order to achieve followup interview completion most followup interviews were conducted in community settings preferred by participants such as fast food outlets the strategies achieved 94 retention at one month followup and 92 retention at six month followup the authors estimated that the additional tracking and retention strategies cost approximately usd85 per participant per followup wave altruism and benefits of research some studies reported appealing to participants altruism in terms of the benefits the research might generate to people like themselves 30407172 this was often included in participant letters or reinforced during contact with interviewers building relationships and trust flexibility in scheduling followup appointments responding to messages positively providing a caring environment being courteous and frequent contact were all strategies designed to build relationships with participants and reduce attrition 16303566 70 71 72 7476158 flexibility in scheduling appointments addresses practical barriers as well such as difficulties with child care or time from work brown et al 72 reported that participants were more likely to remain in clinical trial research if their doctor helped them feel comfortable similarly mcmillan et al 96 credit high retention rates of lowincome pregnant women on the participants midwives involvement establishing a tollfree number where participants can contact researchers free of cost has also been reported 3954 building a project community signorello et al 54 used an annual newsletter for longitudinal research participants providing updates on the research some studies reported appealing to participants altruism in terms of the benefits the research might generate to people like themselves as well as for them 407172 this was often included in participant letters or reinforced during contact with interviewers comparison studies two randomised trials of strategies to minimise attrition were found 2324 festinger et al 23 randomly assigned participants who were receiving treatment for substance abuse to receive 70 100 130 or 160 incentives in either cash or a gift card for returning for a 6month followup the trial found that larger cash amounts resulted in the highest followup rates and fewer additional tracking calls 24 multiple strategies it is worth noting that all studies used multiple strategies to maximise retention commonly involving at least a comprehensive tracking strategy as well as incentives or gifts discussion this is the first literature review to consider all of the research process where representativeness of socially disadvantaged groups may be compromised sampling recruitment data collection intervention delivery and retention while previous reviews exist most are now dated and focussed on one point in the research process mainly the recruitment or retention of socially disadvantaged groups and do not consider issues of engagement such as compliance with measurement and intervention previous reviews are also limited in scope focusing either on one target group of interest one type of research study design or one type of intervention the current review is greater in scope and comprehensiveness providing the reader with a complete picture of strategies for improving socially disadvantaged group participation in research for any given group within any given research study type and using any given type of intervention strategy based on the outcomes of the 116 primary studies included in the current review and 31 literature reviews a considerable number of barriers to the inclusion of socially disadvantaged groups in health and medical research were identified strategies with good evidence of effectiveness were rare with only nine rcts identified amongst the 116 studies based on this higher level evidence there was no clear dominant strategy the trials found mixed results for the effectiveness of incentives to enhance recruitment of socially disadvantaged groups into research 4243 similarly variations in designs of recruitment letters for socially disadvantaged groups eg hand written or printed 106 generic or culturally sensitive 43 and advance letter or no advance letter 36 found mixed results one trial comparing data collection methods found that telephone interviews resulted in more complete data • contact details of significant others 20307666 practical barriers such as transport difficulties lack of child care lack of leave from work • incentives to study participants as reimbursement for time 182223 24 3039407073768081123 • participantcentred approach personalised tailored individualised approach to followup calls or visits 3954667396123 and flexible protocols 1630356670727476 and providing transport or child care 30 • scheduling followup assessments to coincide with existing appointments 2230 • tollfree numbers 3954 forgetting to return for followup • use of study logos on gifts 74 • phone text message reminders 65 • keep in regular contact 18223065677681118 • highlighting benefits of research during followup contact 30407172 indicates good evidence from randomised controlled trial than mailed health surveys 90 two rcts of strategies for improving intervention fidelity suggest that framing health information in a positive way emphasising progress achieved in the health area 37 and that groupbased health counselling achieved greater outcomes than oneonone counselling for hardtoreach rural participants 88 finally two trials of cash incentives found that larger cash amounts resulted in higher retention rates 2324 a large number of strategies supported by fair and poor research evidence are outlined one dominant theme was community engagement involving community groups and organisations in study design sampling recruitment data collection and intervention delivery was reported as essential by most studies improving recruitment participation and retention acknowledging the significance of community involvement in research with disadvantaged groups the national health and medical research council 159 in australia requires that health research with aboriginal participants includes substantial and formal community involvement at all levels 113114118 an added benefit of community engagement in health research is the enhanced likelihood of facilitating the translation of research outcomes to policy and practice quality of the evidence base synthesising the literature was made complex by the amount of methodological variation between included studies and the decision to combine a review of both barriers and strategies differences in study design and procedures the nature of the health issue under investigation settings and the target population groups limited comparisons across studies a crude levels of evidence hierarchy was used and it must be acknowledged that the usefulness of this approach in examining the research quality is limited for example while the rct presents high level evidence of strategy effectiveness and qualitative research is considered low level evidence of strategy effectiveness qualitative research if conducted well is appropriate research design for gaining an understanding of the barriers to research participation however when considering the studies included in the review which examined intervention effectiveness there were too few rcts to pool data as a result this review does not provide conclusive evidence regarding the effectiveness of the discussed strategies some papers report casestudies or other descriptions of research which were not hypothesisdriven testing of strategies and not high level evidence of effectiveness we included these studies as it is not possible to conduct rcts of some multifactorial strategies instead these case studies provide valuable insights for researchers endeavouring to include socially disadvantaged groups so long as the limitation in the quality of evidence is acknowledged the strength of evidence for many of the strategies reported in this review is largely unknown and further robust experimental trials of those strategies which can be tested are required implications for research practice it is imperative that all types of health and medical research employ strategies to increase the representation of socially disadvantaged groups strategies will need to be designed and tailored according to different study types and research questions in some cases it is more appropriate to target the disadvantaged group of interest in the research in other examples like clinical trials of new medicines it is important that various groups are represented in the overall study sample it is clear from this review that the barriers to research with socially disadvantaged group are numerous and no one single solution to addressing the barriers exists to address multiple barriers and challenges a comprehensive coordinated multipronged approach involving many strategies across all stages of research needs to be adopted this has significant time cost and data ownership implications firstly a longterm view to conducting research with socially disadvantaged groups is necessary developing relationships with communities and community groups including their involvement in the development of procedures and study resources and extensive formative research and pilot testing require a considerable amount of time providing collaborating communities and groups with adequate feedback following the conclusion of the study and in some cases interventions or treatments further extends project timelines these activities ought to be reflected in project timelines and acknowledged by academic institutions employing researchers who conduct studies with socially disadvantaged groups this longterm view should also be extended to publication of research with socially disadvantaged groups secondly many of the strategies are resource intensive and entail costs which may be additional to the usual costs of managing a research project the addition of translation services or bilingual research staff flexibility regarding data collection locations or times gifts and incentives culturally tailored resources and materials extensive participant tracking procedures and additional staff training require consideration of costs some strategies such as including all family members in a study to avoid random selection 113 or offering those randomised to control conditions other types of interventions or treatments 148 may increase study costs significantly these costs can be justified in funding applications and need to be recognised by funding organisations finally in some cases of community collaborative research data ownership may need to be negotiated and joint authorship with nonacademic collaborators included academic researchers need to be supported by their academic institutions and scientific journals for publishing collaborative research which may take longer to produce due to authorship negotiations the establishment of research centres or research collaborations dedicated to high quality health and medical research with socially disadvantaged groups is one model for addressing many of the issues raised in this review in a coordinated manner 160161 numerous benefits would flowon from these research centres including pooling of funding and resourcing drawing on multidisciplinary expertise promoting a highlevel research culture in the field expansion in the development of partnership links and networks with community organisations and groups which would increase access and recruitment and training and building the capacity of future leaders in health research with socially disadvantaged groups furthermore a research collaborative could initiate and maintain a research participant registry for improved access to participants from numerous socially disadvantaged groups 25 this review found a number of strategies and methodologies that may have a negative impact on health inequities for example the use of incentives which have considerable evidence for improving recruitment and retention in the general literature 162 have negative connotations in some cultures 80 also some commentators have raised ethical concerns regarding the use of incentives with research participants who may be financially compromised 163 festinger et al 2324 however provided compelling evidence in their trials of cash incentives with people in substance abuse treatment participants in these trials did not use the cash incentive to purchase illicit substances and did not perceive the incentives as coercive highlighting the need to test strategies with target groups for both positive and negative effects similarly the way language is used and information framed 37 can have a negative impact on the reactions of some groups to health research it is difficult to generalise results from one disadvantaged group to another as different cultural factors may be influencing reactions and outcomes implications for health policy and services knowledge gained from health research particularly health services research is used to inform the development or improvement of health policy and health care if a diversity of the population of health service users is not included service delivery is likely to be inequitable doherty et al 164 have identified three main hardtoreach groups within service involvement 1 the underrepresented 2 the invisibleoverlooked and 3 the service resistant reports suggest that the same types of barriers that result in underrepresentation in health research also lead to underrepresentation in health service usedistrust of authorities health literacy and communication difficulties and pragmatic financial transport or employment related barriers 165 an improvement in the representation of vulnerable groups in health research particularly health services research is likely to yield benefits through more equitable service delivery and engagement tudorhart first showed that the individual requiring the greatest effort to attend a health service is also the one with the greatest need 166 while involving socially disadvantaged groups in activities may be resourceintensive and challenging it has been argued that where sufficient funds allow the development of more creative approaches it should be possible to engage with all members of society 167 the strategies described in this review as potentially effective at increasing involvement in health research may be generalizable to improving access and use of health services study strengths and limitations the main limitation of the study is the extent of methodological variation in the studies included in the review the extent of heterogeneity between studies prohibited combining the results statistically in a metaanalysis the inclusion of low level evidence also prohibits conclusive comments regarding the effectiveness of many of the strategies discussed in this review however this could also be considered a study strength as well few rcts were identified to provide a complete assessment of the effectiveness of strategies and inclusion of descriptive studies and casestudies provides valuable insights into ways to increase research with socially disadvantaged groups worth further testing finally the majority of studies included in the review were conducted in developed countries and may not be generalizable to other countries conclusion representativeness can be threatened at various stages of the research process and researchers must remain mindful of whom they may be excluding in the design and implementation of research studies and employ strategies to avoid this happening researchers are in a powerful position to influence inequities in health outcomes generation of research findings that are representative of all social groups will allow development of an evidence base that can be used by service providers and policy makers to deliver programs and policies that reduce health inequities research funding agencies also play a role in ensuring that they fund research that demonstrates consideration of representativeness in its design budget and timelines given this type of research is likely to be more complex costly and timeconsuming however as the world health organisations commission on the social determinants of health notes the increased investment is highly worthwhile as addressing health inequities will result in health social and economic benefits for all of society 10 competing interests the authors declare that they have no competing interests

background this study aims to review the literature regarding the barriers to sampling recruitment participation and retention of members of socioeconomically disadvantaged groups in health research and strategies for increasing the amount of health research conducted with socially disadvantaged groups methods a systematic review with narrative synthesis was conducted searches of electronic databases medline psychinfo embase social science index via web of knowledge and cinhal were conducted for english language articles published up to may 2013 qualitative and quantitative studies as well as literature reviews were included articles were included if they reported attempts to increase disadvantaged group participation in research or the barriers to research with disadvantaged groups groups of interest were those described as socially culturally or financially disadvantaged compared to the majority of society eligible articles were categorised according to five phases of research 1 sampling 2 recruitment and gaining consent 3 data collection and measurement 4 intervention delivery and uptake and 5 retention and attrition results in total 116 papers from 115 studies met inclusion criteria and 31 previous literature reviews were included a comprehensive summation of the major barriers to working with various disadvantaged groups is provided along with proposed strategies for addressing each of the identified types of barriers most studies of strategies to address the barriers were of a descriptive nature and only nine studies reported the results of randomised trials conclusions to tackle the challenges of research with socially disadvantaged groups and increase their representation in health and medical research researchers and research institutions need to acknowledge extended timeframes plan for higher resourcing costs and operate via community partnerships

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introduction the ongoing outbreak of coronavirus disease was first reported in december 2019 in wuhan china covid19 is caused by a betacoronavirus severe acute respiratory syndrome coronavirus 2 that affects the respiratory system 1 despite draconian sanitary measures being applied worldwide covid19 was declared a pandemic on 11 march 2020 by the world health of organization 2 by may 13th the outbreak had infected over 4 million people and caused almost 300000 deaths worldwide there is a longestablished epidemiological observation that social adversity associates with reduced host resistance to infection and disease 3 which goes back as far as 1976 4 more recently it was recognized that the effect on adult immune function and disease risk was much stronger when the exposure to adversity occurred during early life 56 humans are not fully developed at birth nervous and immune systems are gradually developed and educated up to the age of two in fact human life commences and develops for the first 1000 days starting from fetal conception any prenatal complications and postnatal adversity faced defines the lifelong health trajectory 7 as the covid19 pandemic has progressed it has become clear there are many inequalities in susceptibility and severity of the disease the recent flurry of preprint clinical data from many countries worldwide including china uk us are strongly concordant the lower the current socioeconomic status the greater the risk 8 however the role of the early life period and the resultant lifecourse has so far not been investigated to understand the mechanisms underlying these differences we need to dissect the exposome and environmental factors that patients may be or have previously been exposed to there is a wellestablished literature on the role of the overall trajectory from early life through to adulthood and the risk of noncommunicable diseases such as cardiovascular disease diabetes obesity and depression 9 however there is no data on how it affects covid19 although current ses has been associated with the risk progression and even survival of noncommunicable diseases 10 it is now becoming clear that during an individuals life there are periods of increased susceptibility and the overall trajectory of ses may be more important this has led to the barker theory or the developmental origins of health and disease 11 in addition environmental influences which act during early developmentlife may determine our susceptibility to the disease many years later 11 12 13 over time the barker theory has been refined currently this is thought of as a three hit model the three hits are generally accepted as genetic predisposition early life environment and later life environment 1415 as highquality mechanistic studies have addressed the link between the earlylife period and adult disease it is becoming clear that the immune system particularly through chronic lowgrade inflammation and accelerated immunosenescence is mechanistically in the heat of the action in addition we know that stressful experiences during early life induce adaptive responses that are often mediated by the immune system 16 in this manuscript we examine the data linking early life adversity to lifelong disturbances in the immune system that may play a role in determining its ability to fight sarscov2 infection potentially determining the severity of covid19 disease and expanding dohad to cover infectious diseases later in life furthermore we review known factors of ela and their potential influence on the adult immune system and contemplate what kind of data should be collected to understand how ses and ela influence disease susceptibility and severity of covid19 and other diseases we hope this work will contribute in protecting and treating people at risk of developing severe covid19 symptom the role of current ses in covid19 morbidity and mortality socioeconomic status or gradient is a combination of education incomes occupation and reveal inequities to privileges or resources between individuals 10 indeed socioeconomic factors are considered as fundamental determinants in human life span wellbeing and health 10 data from influenza pandemics of 1918 and 2009 showed that socioeconomic factors may determine both disease detection rates and overall outcomes 17 18 19 in the early phase of the covid19 pandemic many studies focused on basic criteria to investigate coronavirus spread transmission routes and potential highrisk populations socioeconomic data were unfortunately missing as they are not considered as data of clinical interest 16 however socioeconomic data regroup many relevant factors as daily situations that directly interact with human health 16 evidence is now starting to emerge that covid19 mortality is increased in ethnic minority populations us data indicates that for example in chicago approximately 70 of the deaths were from ethnic minorities 20 detailed data from new york showed that the number of covid19 cases associated with the percentage of dependents in the local population the malefemale ratio and lowincome neighborhoods 21 united stateswide data gave a similar result with proportion of residents 65 years old ethnic minorities malefemales ratio and the overall population density associating with increased frequency of covid19 22 the united kingdom followed a similar profile although the recent uk data only looked at mortality there was a stronger link between covid19 mortality and ses than ethnic background a 1 increase in the lower socioeconomic class increased covid19 mortality by 2 while a 1 increase in ethnic minority increase mortality by only 1 8 although these are preliminary data they agree with shi et al who reported that the most severe cases were mostly agricultural laborers 23 the link between the incidence of covid19 and lower income neighborhoods and lower ses is most likely due to the overall economic conditions such as poverty performing essential public tasks poor quality and overpopulated housing as well as an obligation to use public transport 8 as well as higher rates of known comorbidities including type 1 and 2 diabetes as well as cardiovascular disease and hypertension 24 overall despite the scarcity of the data we interpret what is available as a suggestion that current ses and neighborhood influence the morbidity of sarscov2 infection and covid disease rather than the mortality rate the role of early life in determining lifelong health trajectories when considering the earlylife environment many measures such as ses are broad and encompass many concurrent elements we have previously found it useful to separate these into four principal subcategories 15 although determining the contribution of each of the four elements is difficult there are data on welldefined exposure conditions that fit into these subcategories as well as insidious general measures like ses int j mol sci 2020 21 x for peer review 3 of 22 socioeconomic data regroup many relevant factors as daily situations that directly interact with human health 16 evidence is now starting to emerge that covid19 mortality is increased in ethnic minority populations us data indicates that for example in chicago approximately 70 of the deaths were from ethnic minorities 20 detailed data from new york showed that the number of covid19 cases associated with the percentage of dependents in the local population the malefemale ratio and lowincome neighborhoods 21 united stateswide data gave a similar result with proportion of residents 65 years old ethnic minorities malefemales ratio and the overall population density associating with increased frequency of covid19 22 the united kingdom followed a similar profile although the recent uk data only looked at mortality there was a stronger link between covid19 mortality and ses than ethnic background a 1 increase in the lower socioeconomic class increased covid19 mortality by 2 while a 1 increase in ethnic minority increase mortality by only 1 8 although these are preliminary data they agree with shi et al who reported that the most severe cases were mostly agricultural laborers 23 the link between the incidence of covid19 and lower income neighborhoods and lower ses is most likely due to the overall economic conditions such as poverty performing essential public tasks poor quality and overpopulated housing as well as an obligation to use public transport 8 as well as higher rates of known comorbidities including type 1 and 2 diabetes as well as cardiovascular disease and hypertension 24 overall despite the scarcity of the data we interpret what is available as a suggestion that current ses and neighborhood influence the morbidity of sarscov2 infection and covid disease rather than the mortality rate the role of early life in determining lifelong health trajectories when considering the earlylife environment many measures such as ses are broad and encompass many concurrent elements we have previously found it useful to separate these into four principal subcategories 15 although determining the contribution of each of the four elements is difficult there are data on welldefined exposure conditions that fit into these subcategories as well as insidious general measures like ses immune adaptation mediated by early life adversity earlylife adversity is broken down into its four key components psychosocial stress infectious stress nutrition and the microbiome and pollutant exposure they are linked to increases in the numbers of senescent cytotoxic lymphocyte which upon stimulation are resistant to apoptosis and release large quantities of expression of proinflammatory certain elements have also been shown to alter the underlying transcriptional identity of leucocytes such as macrophages dendritic cells or t figure 1 immune adaptation mediated by early life adversity earlylife adversity is broken down into its four key components psychosocial stress infectious stress nutrition and the microbiome and pollutant exposure they are linked to increases in the numbers of senescent cytotoxic lymphocyte which upon stimulation are resistant to apoptosis and release large quantities of expression of proinflammatory certain elements have also been shown to alter the underlying transcriptional identity of leucocytes such as macrophages dendritic cells or t lymphocytes this phenomenon is called the conserved transcriptional response to adversity early life psychosocial stress there is now a growing literature on the effects of earlylife psychosocial adversity on the immune system we have previously reported the immunophenotype of young adults that had experienced ela as institutionalization after separation from their parents and subsequently adopted in early childhood compared to those reared by their biological parents 25 in this cohort we surveyed the innate humoral and adaptive immune system we observed an increase in activated and senescent proinflammatory t cells particularly those expressing hladrcd25 and cd5 senescence is a natural aging process affecting all cells including immune cells these begin to deteriorate and this leads to weakened immune responses 26 furthermore there was a trend toward an increase in the number of circulating th17 cells 2728 ela clearly accelerated tlymphocyte maturation and senescence although did not affect b cells tlymphocytes were accelerated through their maturation cycle from naïve to effector memory and aggregating in the terminally differentiated effector memory cells reexpressing cd45ra cell phase 2728 this skewing of the immune system in particular the cytotoxic cd8 tcells was confirmed in an independent cohort of teenagers approximately 15 years after a similar form of ela 29 telomere length decreases with chronological and biological age after cell division and is a hallmark of cellular senescence exposure to stressful events during childhood showed that the telomere length is shorter in these individuals when compared to the control group 30 31 32 33 confirming that ela negatively contributes to an imbalanced immune system 34 furthermore cohen et al showed that low childhood ses significantly decreased the telomere length later in life of a cd8cd28t cell population which play major role in the response to viral infections 35 studies with rodents produced the predominant hypothesis that the mechanism by which ela impacts the function of cd8 cells and consequently viral responses may be through the hpa axis ela negatively impacts the hpa axis which programs its effects and responses later in life this normally results in a decreased release of corticosterone or cortisol after exposure to stress which consequently has a great impact on the peripheral immune system leading to compromised viral responses 36 37 38 39 however results from mechanistic studies in our epipath cohort have excluded this we were able to show that despite an altered hpa axis 25 glucocorticoid signaling and the peripheral hpaaxis stress system were not epigenetically programed 40 implying that the immune system was directly impacted early lifeinfections it is well known that an early life exposure to infection and inflammation can have devastating effects one example would be that neonates suffering from bacterial or viral sepsis are about threefold more likely to die within the first 120 days 41 there is also evidence showing that sepsis in newborns was associated with poor longterm neurodevelopment 42 the immediate risk of infection to the organism especially for those more vulnerable seems obvious the longterm consequences of an infection prove far more difficult to grasp bilbo and schwarz reviewed available data on the connection between perinatal infection and longterm effects on stress reactivity and cytokine production 43 showing that early life infection leads to a cytokine storm infection and an overall higher risk of childhood infections due to the institutionalization 2527 a very recent study in zebrafish shows that expression of several proinflammatory genes is increased in adult fish after early life bacterial infection 44 this study also showed that the age of the first infection is a crucial factor for the adult immune response other studies have specifically linked earlylife respiratory viral infection with a higher likelihood to develop diseases like childhood asthma or allergies 45 46 47 or the chance to develop type 1 diabetes 48 these chronic conditions are known risk factors for a more severe outcome of covid19 disease currently the molecular mechanisms in which an early life infection distorts the immune system are only partially understood in invitro experiments fonseca et al demonstrated that earlylife exposure to bacteria in combination with respiratory syncytial virus later in life can lead to epigenetic modifications impacting bone marrow progenitor cells and therefore causing longterm reshaping of inflammatory mediators and metabolic profiles 49 subsequently all daughter cells of these progenitors would be illequipped to handle subsequent infections 47 certainly early life infections present a specific type of early life adversity it is indubitably linked to the overall health of the individual and the social environment given that hosttohost transmission of pathogens are by far the most prevalent form of infection in the previous section we showed the impact of psychosocial stress on the immune system however the overlap does not end there sickness in humans and animals also changes their social behavior well known behavioral changes include a decrease in activity and expanded sleeping periods 50 therefore social behavior and infection should not be treated as two distinct adversities but as two sides of the same coin early life nutrition and the microbiome over the last decade it has become clear that once the microbiome is established it is shaped by the exposome and the 9 million microbial genes it encodes and play a crucial role in determining host development and health 14 51 52 53 modulating the host most probably protects the natural enteric symbiotic microbial community and disturbing the established microbiome producing a dysbiosis results in disease and may even be fatal 5455 the microbiome established is dependent on the route of birth and is then modulated by nutritional intake living conditions the polluted environment and the presence of pets 5657 as sarscov2 appears to persist in the gi tracts and can be detected in human feces 5859 it will interact affect and be affected by the microbiome indeed diarrhea is now recognized by the centers for disease control and prevention as a covid19 symptom and it is a clear sign of microbial dysbiosis 60 the interaction and effects of sarscov2 will almost certainly depend on both the microbiome that has been established and how the host has adapted to its microbiome the lps content and immunostimulatory potential of the initial earlylife microbiome depends on the birth route 51 the microbiome is established during a sensitive period in which the newborn immune system is primed 61 and may explain why babies born by caesarean section have a significantly increased risk of allergy or asthma later in life 62 exposure of newborns to a more diverse microbiota soon after birth altered both the disease susceptibility and maturation of specific immune cell subsets whereas if the first encounter occurred later immune dysfunction was not corrected 6364 regulatory t cells play a significant role in the host adaptation to the microbiome recognize hostspecific commensal bacteria derived antigens 65 and result in longterm tolerance to the enteric microbiome 66 it would appear that adverse microbiota is essential for the immune system to fully mature 67 perinatal viral infections such as cmv have been extensively studied and linked to lifelong changes in the microbiome 68 and common viruses such as influenza are known to affect the development of the immune system when acquired at birth and during infancy 69 the angiotensinconverting enzyme 2 receptor may play a role in determining microbiomeimmuneinteractions in the gi tract ace2 is expressed in enterocytes and is important for maintaining both antimicrobial peptide expression and the overall health of the microbiome 7071 mice lacking ace2 develop gut absorption related diseases 7072 as sarscov2 uses ace2 receptor to enter cells 7374 it would be logical to assume that there is a link between the virus and the microbiome that was established in early life immune cells resident in the gi tract and the overall outcome of covid19 early lifepollution exposure there is emerging evidence that environmental exposure to pollutants during sensitive developmental periods like early life could be a strong factor of susceptibility predisposing the individual to birth outcomes and disease onset in later life 15 prenatal exposure to airborne pollutants could affect fetal reprograming by epigenetic modifications and may therefore explain the potential link between air pollutant exposure and adverse pregnancy outcomes epidemiological studies have pointed out causal association between fine particulate matter and neurodevelopmental neurodegenerative 15 metabolic cardiovascular 75 and lung pathologies 76 air pollutants were therefore proved to affect key cellularmolecular targets during the perinatal period which are susceptible to alter immune responses link to abnormal respiratory functions and lung diseases later in life 77 for instance the eden birth cohort study focusing on determining perinatal factors that influence childhood health and social development pointed out that a prenatal exposure to pm10 was linked to an increased in cd8 t cell and a decreased in regulatory t cells in infants at birth leading to a potential increase in the susceptibility of viral infection responses as well as atopy development in children 78 the impact of traffic pollutants and tobacco smoke on regulation of numerous immune relatedgenes such as cytokines tlr2 nitric oxide synthases and several factors of transcription has also been demonstrated 77 it is now well established that modifications in dna methylation patterns due to pm 25 exposure are frequently associated with the development of lung pathologies 79 however it remains difficult to assess whether exposure during early life has a stronger impact on development of diseases than that of the adulthood or whether substantial morbidity is the result of accumulated exposure 76 in the context of covid19 zhu et al demonstrated significant associations between air pollution and covid19 infection high concentration levels of pm 25 pm 10 co no 2 and o 3 were therefore positively linked to a risk of covid19 infection whereas high concentration levels of so 2 were negatively linked to the number of daily covid19 confirmed cases 80 these results are supported by those obtained in february 2020 by martelletti et al who showed that in the industrialized regions of northern italy those most affected by covid19 the concentration levels of pm10 and pm25 were above the legislative standard limit of 50 µg per day 81 the adsorption of sarscov2 rna on airborne pm was established in these regions by setti et al who suggested that in conditions of atmospheric stability and high concentration of pm sarscov2 could create clusters with outdoor pm and by reducing their diffusion coefficient enhance the persistence of the virus in the atmosphere 82 in a crosssectional observational study conducted in the united states wu et al showed by taking into account 20 potential confounding factors in their main analysis that a slight increase in pm25 was linked to an 8 increase in the rate of covid19 death 83 although all this data results from preliminary investigations it tends to suggest a positive relationship between ambient air pollution exposure and covid19 mortality rate confirming the direct impact of airborne pollutants on the covid19 severity could prove an asset in terms of public health and prevention strategy in places with poor air quality we have previously highlighted the role of earlylife pollution exposure and a potential second hit in the threehit model producing a quiescent phenotype likely encoded in the epigenome which might become vulnerable in later life to a third environmental hit such as covid19 15 given the longterm effects on health of earlylife pollutant exposure and the linkage with the development and progression of pulmonary pathologies in laterlife it is reasonable to assume that earlylife pollutant exposure will affects the course of covid19 early life origins of covid comorbidities if the early life environment plays a role in determining the outcome of covid19 examining its role in the key comorbidities is essential the three key comorbidities determining covid19 severity are cardiovascular disease hypertension and diabetes the seminal work of david barker clearly identified the role of the inutero environment another source of early life adversity in determining the risk of both cardiovascular disease and hypertension while this has been extensively reviewed elsewhere 84 85 86 it is worth noting that the relative risk associated with birthweight and ponderal index is by far larger than any other risk factor identified for either disease to date there is now a large body of evidence showing diabetes to be a major risk of complications and death after sarscov2 infection 87 as in previous coronavirus outbreaks 88 while the risk of sarscov2 infection appears to be similar 89 like the other elements discussed here type 2 diabetes may have its origins in early life there are wellestablished classical risk factors that contribute to t2d including obesity age stress inflammation diet lifestyle and environment however there is growing recognition for nonclassical factors such as pollution exposure to ionizing radiations and low socioeconomic status the classical and nonclassical factors are intimately intertwined ses is a broad measure encompassing prior life history and low ses also increases the risk for obesity stress environmental and lifestyle factors as well as a proinflammatory phenotype 90 the importance of t2d in determining covid19 severity may in part be due to treatment strategies currently used in t2d together with another severe comorbidity hypertension both are often treated with ace inhibitors and arbs these increases ace2 expression in pancreatic islets lungs intestines etc 91 sarscov2 exploits these ace2 receptors to enter host cells thus potentially increasing the risk of infection in t2d patients 92 increased pancreatic ace2 activation has been reported to inflict beta cell damage complicating the prognosis 93 and further contributing to the characteristic cytokine storm observed in covid19 cases other t2d drugs that induce ace2 expression include pioglitazone liraglutide gliflozins and dpp4 inhibitors and have also been implied to promote coronavirus predisposition 94 this may be further accentuated by hyperglycemiainduced ace2 glycosylation ace2 glycosylation is also a prerequisite for the virus to latch onto the ace2 receptors 95 this enhancement is reversible by strict glycemic control 95 as such glycemic and overall diabetic status have been proposed as predictors of covid19 severity and mortality 96 although current t2d status may play an important role in sarscov2 susceptibility and covid19 severity it is part of a larger etiopathological risk complex t2d may have its origins in the early life social environment low earlylife ses showed a clear strong association with individual metabolic profiles that was not true for current ses 97 this result has been replicated by another study that highlighted the effect of ses during adolescence on the development of t2d up to fifty years later 98 more recently chandan et al reported a retrospective populationbased cohort of 80657 adults that had been exposed to ela and 161314 unexposed controls this seminal study clearly demonstrated the link between childhood maltreatment and cardiovascular disease hypertension and t2d in a population where ela rates may reach 25 their data clearly shows that a significant proportion of the cardiometabolic and diabetic disease burden may be attributable to maltreatment 99 there is now some mechanistic evidence to back up the link between ela and t2d needham et al investigated the transcriptional effects of low ses 100 they reported that low adult ses altered the expression of several genes intimately linked to inflammation that are all linked to t2d 104 and tlr3 105 and stress related gene avp 106 furthermore low earlylife ses was also shown to affect the expression of stress related genes fkbp5 107 oxtr 108 and avp and inflammation associated genes cd1d and ccl1 as such ses would appear to act on inflammatory pathways that are common to low ses environments and eventually t2d and may worsen the t2d etiopathology by targeting prominent pathophysiological factors like stress and inflammation the mechanistic link between ela and t2d is reenforced by the immune disturbances reported patients with t2d have a larger number senescent cd8 cytotoxic t cells and higher levels of systemic inflammation 109110 that may explain the higher incidence of viral and bacterial infections in diabetic patients 111 f8 101 cd1d 102 klrg1 103 nlrp12 although there is no data currently available it is logical to assume that although t2d may predict covid19 severity the origins of this link may lie in the lifelong proinflammatory environment induced by ela t2d may be the adult manifestation of the poor early life social environment which then mediates the effect between ela and covid19 the covid19 immune response ses and early life adversity the immune response to covid19 the sarscov2 like other viruses is considered immunologically as an intracellular parasite in general the viral infectiouscycle starts with a shortlived extracellular period followed by cell entry with a final longer intracellular replicative period in the classical antiviral immune response the immune system attacks all phases of the viral cycle using both antigen specific and nonspecific mechanisms the nonspecific immune response particularly effective in the early phase of infection is mainly mediated through natural killer cells and interferons production andor secretion of type1 interferons enhances nk cell ability to lyse infected cells as well as inhibits viral reproduction and cellular proliferation when an adaptive immune response has been mounted the most effective antibodies are the socalled neutralizing antibodies which block viral entry into the host cell by binding to viral surface proteins such as the envelope or capsid protein when the subsequent cellmediated immunity enters into force it is principally cd8 cytotoxic t lymphocytes that are the effector cells ctls recognize mhc classi presented antigens to lyse the presenting cell a response that is not always beneficial as the damage done by the cytotoxic cells is occasionally greater than that of the virus itself int j mol sci 2020 21 x for peer review 8 of 22 the immune response to covid19 the sarscov2 like other viruses is considered immunologically as an intracellular parasite in general the viral infectiouscycle starts with a shortlived extracellular period followed by cell entry with a final longer intracellular replicative period in the classical antiviral immune response the immune system attacks all phases of the viral cycle using both antigen specific and nonspecific mechanisms the nonspecific immune response particularly effective in the early phase of infection is mainly mediated through natural killer cells and interferons production andor secretion of type1 interferons enhances nk cell ability to lyse infected cells as well as inhibits viral reproduction and cellular proliferation when an adaptive immune response has been mounted the most effective antibodies are the socalled neutralizing antibodies which block viral entry into the host cell by binding to viral surface proteins such as the envelope or capsid protein when the subsequent cellmediated immunity enters into force it is principally cd8 cytotoxic t lymphocytes that are the effector cells ctls recognize mhc classi presented antigens to lyse the presenting cell a response that is not always beneficial as the damage done by the cytotoxic cells is occasionally greater than that of the virus itself figure 2 the immune reaction to coronavirus disease the adaptive response to sars cov2 is a classical antiviral response on the right side once recognized by antigen presenting cell th2 response is activated and induced maturation of b cell after maturation precursor b cell produces a specific antibody against sarscov2 while mature b cell retain memory of sarcov2 to produce antibodies in case of new infection once the th1 system is activated it induces activation of precursor cytotoxic lymphocyte t due to expression of many cytokines in one hand effector can release proteins as granzyme to destroy infected cell in case of mild infection in case of severe infection ctl become exhausted and express pd1 tigit and ctla4 in patients with having experienced ela the increased relative number of sctl having lost cd28 expression will produce a less efficient lysis of sarscov2 infected cells the recognition and clearance by nk cells and the initial role if interferons is omitted for clarity cell images were from with the right to reuse them as the covid19 pandemic has progressed there have been several reports of the antisarscov2 immune response to date the data suggests that the response is a classical antiviral response with activation of type1 interferons and cd8 ctls although thevarajan et al analyzed a single patient they nicely demonstrated the kinetics of the antisarscov2 immune response 112 in a manner similar to both influenza infection and a previous sarscov2 report 113 which showed the adaptive response to sarscov2 is a classical antiviral response on the right side once recognized by antigen presenting cell th 2 response is activated and induced maturation of b cell after maturation precursor b cell produces a specific antibody against sarscov2 while mature b cell retain memory of sarcov2 to produce antibodies in case of new infection once the th1 system is activated it induces activation of precursor cytotoxic lymphocyte t due to expression of many cytokines in one hand effector can release proteins as granzyme to destroy infected cell in case of mild infection in case of severe infection ctl become exhausted and express pd1 tigit and ctla4 in patients with having experienced ela the increased relative number of sctl having lost cd28 expression will produce a less efficient lysis of sarscov2 infected cells the recognition and clearance by nk cells and the initial role if interferons is omitted for clarity cell images were from with the right to reuse them as the covid19 pandemic has progressed there have been several reports of the antisarscov2 immune response to date the data suggests that the response is a classical antiviral response with activation of type1 interferons and cd8 ctls although thevarajan et al analyzed a single patient they nicely demonstrated the kinetics of the antisarscov2 immune response 112 in a manner similar to both influenza infection and a previous sarscov2 report 113 which showed that the numbers of cd38 hladr cd8 t cells were higher in infected patients than in healthy controls and rapidly increased from 357 532 to a peak at 118 9days later by day 20 they had decreased slightly to 705 as would be expected cd38 hladr cd8 ctls produced significant quantities of the lytic moietiesperforin granzyme a and granzyme bnecessary to lyse virusinfected cells their kinetic data showed that this occurred at days 79 preceding symptom resolution suggesting an important role in the resolution of the sarscov2 immune response 112 the anti sarscov2 immune response in severecritical patients covid19 patients are generally considered either mild severe or critical there are now data on the differences in the immune response in these different categories although the categories are not always the same complicating comparisons between studies when zheng et al investigated tcell derived functional molecules they highlighted lower levels of interferonγ and tnfα in cd4 t cells in severely affected patients than those mildly affected although in the latter they were considerably higher than expected in health controls 114 levels of perforin and granzyme b cells were increased in cd8tigitctls and the numbers of senescent hladr tigit cd8 cells were increased in severely affected patients than those with a mild infection the authors proposed that their data suggests covid19 like many chronic viral infections reduces cd4tcell functionality skewing the immune response towards a cd8 response with excessive activation leading to exhaustion of the cd8 cells diminishing the antiviral immune reaction furthermore upon deeper examination they found differences in pd1 ctla4 and tigitmarkers of immune exhaustion in severely affected patients exhausted pd1ctla4tigit cells were significantly more frequent than in patients with a milder infection this excessive ctl exhaustion may reduce the effectiveness of the immune response to sarscov2 explaining case severity 114 furthermore in an independent study it was also reported that as disease severity increases the numbers of naïve effector and memory classes of cd8 t cells diminish while bcell and cd4 t cell numbers generally increase 115116 overall we interpret these data as showing that a functional cd8 response is required to clear sarscov2 infection and covid19 severity is increased as the cd8 response becomes somehow diminished indeed omarjee et al have also come to a similar conclusion that severe covid19 can therefore mimic a state of immune senescence 117118 from the start of the pandemic the involvement of the cytokine system was clear 119 initially described in january 2020 levels of cxcl8 and ifnγ were increased in all covid19 patients and severe cases had significantly higher levels cxcl10 ccl2 and tnfα than milder cases 120 reproduced in a more recent study that also observed increased levels of il6 and il 10 in the most severe cases 121 does immunosenescence link ela to covid19 outcomes we have outlined above the elainduced long term immunophenotype although the origins are multifactorial it would appear from the work of elwenspoek 2728 and reid 29 that an adverse social environment in early life drive tcells in particular cd8 ctls towards a senescent state when the different aspects of ela are considered separately immunosenescence would appear to be a common aspect senescence and exhaustion may have similar outcomes a reduced immune reaction but are distinct processes 122 senescent cells have a significantly reduced capacity to proliferate however they have a strong proinflammatory action in a manner reminiscent of the senescence associated secretory phenotype initially established in fibroblasts 123 senescent cd8 ctls aggregate in the highly differentiated states are highly resistant to apoptosis and produce significant quantities of proinflammatory cytokines such as il6 and tnfα upon stimulation 124 exhausted cd8 ctls however are not only unable to proliferate but they no longer secrete cytokines after stimulation and are programed to undergo apoptosis the data currently available suggests that the aggregation of senescent ctls will negatively impact the progression of covid19 and patients with the most senescent ctls will have the poorest prognosis as they are less capable of mounting an effective cd8 response and they will have an exaggerated cytokine secretion from the senescent cells this is further supported by the recent initiation of the scope trial sirolimus treatment in hospitalized patients with covid19 pneumonia in this trial the investigators propose administering rapamycin to downregulate the il6 pathway through the mtor pathway to not only reduce ilβ levels but reduce the number of senescent tcells as well 117 this also raises the question about what happens to covid19 when elainduced senescence and covidinduced exhaustion converge it would seem logical to hypothesize that this would represent the worstcase scenario and would produce the leasteffective cytotoxic t cell response the conserved transcriptional response to adversity studies have demonstrated that early life social adversity can act mechanistically through modifications of gene expression patterns gene expression implicated in the activation of tlymphocyte and inflammation was enhanced while gene expression implicated in innate antiviral responses induced by type i ifn and innate antimicrobial responses of pathogenspecific was reduced 125 these patterns of altered gene expression remain lifelong 125 the pattern has been termed the conserved transcriptional response to adversity and has been noticed in many correlational studies regarding humans encountering with adverse life circumstances 126 127 128 129 130 131 132 133 ctra dynamics are most strongly induced by social conditions in early life at the first step of the development of postnatal immune system 125 to the extent that transcriptome remodeling induced environmentally continue to affect immune responses of implicated pathogen many many years later in life essential covariates ela is however associated with a range of negative health behaviors including an increased risk of smoking as well as increased smoking levels levels of alcohol consumption and poor diet leading to either malnourishment or obesity the psychobiological and neurodevelopmental mechanisms linking ela and risky health behaviors are starting to be dissected 137 however in the context of the covid19 pandemic it would appear from the numerous studies that are becoming available that smoking increases the risk not only of hospitalization with covid19 but with icu admission and death and was confirmed in recent meta analyses of the available studies 140 141 142 143 on the other hand there is little evidence available on the role of prior alcohol intake on the course of sarscov2 infection however considerable public health efforts are being made to combat alcohol abuse during the confinement period and a prior history of ela exposure may increase the risk of excessive alcohol consumption during this period biological sex is one of the strongest drivers of the heterogeneity in covid19 disease severity there is a clearly more favorable outcome for women across all age categories the data available so far suggests that sexual dimorphism in the immune system may play a role in determining disease outcome sex impacts not only the development of t reg cells but the distribution of lymphocyte subsets and the overall tlymphocyte response to challenge 144 many immunologically important genes are found on the xchromosome including cd40l and cxcr3 incomplete xinactivation or epigenetic modifications will induce sexspecific effects on tcells 145146 there is also evidence that there is a stronger lymphopenia in males than females in severe covid19 disease 147148 there is also growing evidence for the role of vitamins d and k in the outcome of covid 19 disease beyond its classical role in bone metabolism 149 vitamin d plays a role in the functioning of the immune system and in the regulation of inflammatory cytokines 150 and crp 149 which reduces the risk of infection and cardiovascular disease 149 indeed immune cells like tcells bcells or antigen presenting cells can directly interact with vitamin d receptors in this way increased vitamin d levels enhance the innate system and suppress the adaptive immune system which demonstrates its role in immune regulation 151 vitamin d deficiency is also linked to comorbidities such as diabetes 152 and upper respiratory disease susceptibility including common viral infections allergies and airway inflammatory conditions the logical assumption is that a possible explanation on the susceptibility of the elderly population is the fact that they naturally produce less vitamin d while they are exposed to less sunlight as many stay indoors considering also that the pandemic first made its global appearance during winter season increases the possibility for this correlative association 152 panfili et al highlighted the potential that vitamin d supplementation has shown to be a successful costeffective therapeutic for acute respiratory tract infections in low socioeconomic characterized countries 153 in addition studies have shown that vitamin d can help to reduce the risk of an activated reninangiotensin system in the lung 154 in cases of severe covid19 disease in patients with hypertension and high expression of ace2 receptors 155 on the other hand patients with comorbidities such as diabetes present a lack in vitamin k which is involved in blood coagulation or bone calcification mechanisms in case of covid19 patients insufficient levels of vitamin k could be associated with a risk of complications due to elastic fiber pathologies such as idiopathic pulmonary fibrosis 156 coagulation has been reported as a common comorbidity linked to covid19 severity and mortality covid19 as a natural experiment given the obvious ethical objections to experimental studies manipulating the early life environment there is a long history of using natural experiments there are two classical natural experiments looking at the early life social environment project ice storm in canada and the dutch hunger winter when we look at these natural experiments in the light of the threehit model these examined the role of the second hit the early life environment project ice storm is based on the 1998 quebec ice storm and examines the impact of prenatal stress on adult outcomes this particularly harsh meteorological event affected residents of a well delineated area covering nova scotia new brunswick southern quebec and eastern ontario these populations had to deal with a situation where they were deprived of electricity for weeks and in certain cases months as well as the shutdown of all activities in major cities as well as military deployment and several deaths project ice storm went on to examine the effects over the following 20 years on the children and now young adults that were exposed to the storm in utero 157158 they concluded that prenatal glucocorticoid exposure impacted a variety of outcomes in the next generation throughout childhood and persisting into adulthood dysregulating metabolic pathways and the hpa axis 157159 this was mediated through epigenetic encoding of the storms effect 158 project ice storm demonstrated that an environmental stressor can have longterm effects and inducing numerous outcomes although there were additional mechanisms linked to socioeconomic factors that are still to be identified the dutch hunger winter was the consequence of a food embargo placed on the dutch population by the germans at the end of world war ii 160 here the importance of timing of the adversity in the programing of adult disease was established 161 working on samesex sibling pairs of which only one was exposed to famine they demonstrated that in utero exposure induced an adverse metabolic 162 or mental phenotype 163 depending on the time of exposure and fetal sex and that this was mediated by dna methylation 164 as project ice storm disaster and the dutch hunger winter the current covid19 pandemic must be considered as a relevant natural experiment to reveal the effects of socioeconomic factors on health and disease in the context of the threehit model here we have an exquisite and unique opportunity to investigate the third hit as outlined above the early life period acts through underlying mechanisms such as dna methylation and programing of the immune system to influence disease progression and severity later in life these prior studies have provided unexpected mechanistic insight into the immunological consequences of early life stress exposure drawing parallels with covid if we can collect the correct data we can start to unpick the role of the whole life trajectory and how this contributes to disease risk through a proinflammatory immune bias covid19 may also be a form of early life adversity it is yet to be discovered whether sarscov2 could have any immune programing capacity after an early life infection and what consequences could appear years later its strong association and impact on the early life microbiome is unknown pregnant women who tested positive for sarscov2 infection showed evidence of placental injury which impeded blood flow to the fetus 165 placental development is the first step in embryogenesis and may determine the quality of the intrauterine environment 165166 individuals who were exposed to the spanish flu of 1918 have been reported to face lifelong low ses and cardiovascular diseases 167 which may be indicative of a bidirectional risk that has crossed over from the placenta jeopardizing their lifelong health profile it is quite possible that the covid19 positive mothers pass on a similar risk to subsequent generations serving as an ela event which ultimately makes them highly susceptible thus these cases need strict follow up studies to validate this hypothesis data that should be collected in light of the data presented here it is clear that there are many types of data that should be collected in addition to the studies that are currently ongoing addressing the epidemiology and biology of covid19 as recently highlighted it is essential to collect as much socioeconomic data as possible during the ongoing pandemic 16 data collection should be expanded to include retrospective data on lifetrajectories and both exposure to adverse life events and how importantly they were perceived there are wellrecognized difficulties in retrospectively assessing adversity or the overall lifecourse however there are tools available that can measure the prior traumatic experiences recent adult trauma can be addressed by a brief questionnaire that covers the perceived importance of a range of stressful life events including separation relationship and money worries accidents illness and death job loss and violence 168 that any future study participants may have experienced to address traumatic experiences earlier in life there are also validated questionnaires such as the childhood trauma questionnaire ctq or the early trauma index that are available 169 however as with any retrospective study there is a risk of recall bias although the validated questionnaires have questions within them to ensure internal consistency furthermore in the context of a fastmoving pandemic the ability to transpose such questionnaires to an online system is known to improve the accuracy of responses as the anonymity of the online process has been shown to reduce both social desirability and central coherence biases although there is a potential risk of questions being misinterpreted by participants 170 all such tools are limited by what was thought of as being traumatic when they were developed however they remain the standard tool for assessing traumatic events during childhood as well as a poor social and familial environment 169 the use of such questionnaires has already proven useful adverse social conditions as measured by the ctq have been shown to become embedded as functional changes in the immune system that are visible lifelong studies have shown adversity measured by the ctq over a period of as little as 4 months changes the immune response up to 24 years later the longest timepoint investigated so far 272834125 tools such as the ctq should play a role in studies addressing the overall disease severity if participants go on to develop covid19 rather than whether ela plays a role in the overall prevalence of infection furthermore health related behaviors such as smoking and alcohol consumption which are known to be elevated after ela and may also play a role in the clinical evolution or susceptibility to sarscov2 infection must be recorded all data should be analyzed with a sexinformed approach taking differences in the immune system into account the collection of lifeevent metadata must be complemented by the collection of the correct biological samples we have highlighted the role of the immune system the microbiome and pollution levels it would seem logical to obtain stool and blood samples and the markers to be investigated such as tigit pd1 cd28 and cd57 are now becoming clear furthermore such biosampling would allow the analysis of vitamin levels as they may be a key link in the pathophysiological chain it would also appear to be appropriate to rapidly collect measures of pollutants determine how indoor and outdoor pollution levels have changes how with the strict confinement measures imposed nutrition has changes all of these will play into the susceptibility and immune response the data reviewed here highlights the role that the social environment will play in determining morbidity and mortality during the covid19 pandemic in the future such socioeconomic and lifestyle data must be considered as essential clinical data that is then analyzed concurrently with biological material to tease out the effects of the environment in health and disease conclusions the developmental origins of health and disease is firmly established for many noncommunicable diseases the current covid19 pandemic has shown that there are many health disparities and the available data suggests that there is a strong socioeconomic impact on morbidity and potentially mortality although there are no data sofar available to link the early life period to the morbidity and mortality of an infectious disease an adverse early life environment would appear to impact the immune system and make it less efficient in fighting subsequent viral infections earlylife researchers have a long history of taking advantage of natural experiments teasing out the longterm consequences of ela to produce a measurable phenotype many years or even generations later the current pandemic can turn this paradigm on its head many discrepancies and inequalities in covid19 morbidity and mortality have been reported and if the correct data is collected it may be possible to separate the early life elements that have made people particularly vulnerable to covid19 many years later this will naturally then help us identify those that are most at risk from developing the severest forms of covid19 in order to do this we need to recognize socioeconomic and earlylife factors as genuine medically and clinically relevant data that urgently need to be collected finally many biological samples have been collected in the ongoing studies the mechanisms linking the early life environment with a defined laterlife phenotype are starting to be elucidated and perhaps hold the key to understanding inequalities and differences in the severity of covid19 funding the work of jdt on the long term effects of ela was funded by the fonds national de recherche luxembourg jdt together with ch sbf svs mpm and egc are funded by the fnr convince c19sc13650569 alac c16bm11342695 metcoeps interanr1611568350 madam pride11012546nextimmune and pride1711823097microh respectively jdt is a management board member of the eufunded cost actions ca18211 and ca16120

a poor socioeconomic environment and social adversity are fundamental determinants of human life span wellbeing and health previous influenza pandemics showed that socioeconomic factors may determine both disease detection rates and overall outcomes and preliminary data from the ongoing coronavirus disease covid19 pandemic suggests that this is still true over the past years it has become clear that earlylife adversity ela plays a critical role biasing the immune system towards a proinflammatory and senescent phenotype many years later cytotoxic tlymphocytes ctl appear to be particularly sensitive to the early life social environment as we understand more about the immune response to sarscov2 it appears that a functional ctl cd8 response is required to clear the infection and covid19 severity is increased as the cd8 response becomes somehow diminished or exhausted this raises the hypothesis that the elainduced proinflammatory and senescent phenotype may play a role in determining the clinical course of covid19 and the convergence of elainduced senescence and covid19 induced exhaustion represents the worstcase scenario with the least effective tcell response if the correct data is collected it may be possible to separate the early life elements that have made people particularly vulnerable to covid19 many years later this will naturally then help us identify those that are most at risk from developing the severest forms of covid19 in order to do this we need to recognize socioeconomic and earlylife factors as genuine medically and clinically relevant data that urgently need to be collected finally many biological samples have been collected in the ongoing studies the mechanisms linking the early life environment with a defined laterlife phenotype are starting to be elucidated and perhaps hold the key to understanding inequalities and differences in the severity of covid19

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introduction migration denotes movement of population from one village or town to another village or town the word migration derived from latin word migrare means to change ones residence according to new webster dictionary migration means the act or an instance of moving from one country region or place to settle in another or the act or an instance of moving from one area to another in search of work many scholars have given clear definition for migration safa opines that migration is normally viewed as an economic phenomenon though noneconomic factors obviously have some bearing thus the concept of migration embraces essentially four crucial dimensions space residence time and activity changes its been argued by many economists that rural to urban migration may be due to economic factors but when it comes to indian villages its been seen that migration was a complicated multifaceted event its commonly understood that the main motivation for migration was the different socio economic environment in the place of origin and the place of destination different instances operate the push pull migration theory of bague also has implied that its mostly in the native villages this movement this movement primarily takes place and even their reaching places selected will be more in number many economists have commonly inferred that rural urban migration in any form were mostly poverty induced distressed or subsistence vs developmental occurs due to some economic and noneconomic factors afield survey was conducted on the building sites in pramod layout mysore road ullalupanagarajpnagara and koramangala in bangalore city only women belonging to distressed classes were taken for survey one hundred and fifty samples were collected in north karnataka raichur bijapur yadgirgulbarga bellary koppal bagalkot and bidar suffer from a acute shortage of rainfall and always have drought like conditions they are thus riddled with poverty and look for a source of livelihood elsewhere bangalore a bustling city with a huge population and with a roaring construction business has given sustenance for hundreds of such women and men by giving them jobs in the construction sites but rural migration to urban lands has created a huge space problem in the cities which have expanded since the last two decades how to stem this occurrence which has created many city problems like housing medical facilities the springing of slums crimes lack of educational facilities it has been suggested to introduce 15 cess for construction workers and implement all safety measures and give minimum wages set by the government in 2021 and not that set up in 1948 to alleviate their poverty ngos can distribute midday meals on work sites or even arrange for teaching their children free of cost review of literature according to ravenstein migrants move from areas of low opportunity to areas of high opportunity the choice of destination is regulated by distance with migrants from the rural areas often showing a tendency to move first towards nearby towns and then towards large cities further ravenstein observes that each stream of ruralurban migration produces a counter stream of urbanrural migration although the former tends to dominate the latter he also points out that the urban residents are less migratory than the rural lastly migration accelerates with growth in the means of transport and communication and expansion of trade and industry the importance of the economic motive in the decision to migrate the negative influence of distance and the role of stepmigration is the highlight of ravensteins theory building on ravensteins laws of migration lee divides forces exerting influence on migration perception into pluses and minuses the former pull individuals towards them the latter tend to drive them away there are zeros also in which the competing forces are more or less evenly balanced these forces are associated with the area of origin and the area of destination and are influenced by personal factors which affect individual that facilitate or act as an obstacle to migration brueckner and zenou add an urban land market to a static harristodaro framework and look at the urban area as a monocentric city with an endogenous population an exogenous shock like the enlargement of the modern sector or an increase in the urban wage the unemployment rate and thus the probability of being employed are the forces that restore the equilibrium in this model formal sector growth does not necessarily induce migration enlarging the formal sector causes land rents to rise which may depress a potential migrants expected utility in spite of his better chances of finding a job when this is the case the overall urban population and thus the informal sector must shrink to restore the migration equilibrium research gap with agriculture getting mechanized more and more the subsistence of farm labour has taken a backseat with agricultural wage rates minimum wage floor rate increasing from rs350 per day to 1500rs per day as of 2021 most of the big farmers are trying to minimize the use of labour in their farms with unseasonal heavy rains destroying standing crops and with no other source of employment or sustenance rural urban migration is more prevalent in the post pandemic year objectives 1 to compile the profile of sampled migrant workers 2 to understand causes for migrationwhether distress migration or to increase economic level 3 to analyze the changes in socio economic status after migration 4 to find out if there are any possibilities for these labourers to avail any helpful interventions from government self help groupsanganwadis etc research methodology both primary data and secondary data was used for analysis the primary data consisted of the sample design of scheduled caste and tribal migrants which were taken for study only women were taken as samples they were interviewed face to face sample size was one hundred and fifty and simple random was used to collect samples descriptive analysis was followed as many labourers were illiterate and questionnaire was filled up by the investigator and the interviewed sample put their thumb print in their respective names in the questionnaire their surveyed age groups were 2535 years secondary data comprised of collecting material from previously published articles books and reports from government result and discussion table analysis though the minimum wage rate was fixed at rs1500 it was seen that a paltry amount of rs400600 rs was paid per month which had all the families on the verge of starvation with food inflation prevalent post pandemic the access to two square meals per day was a rarity 2 denotes 2 adults per family and 2 refers to adults and refers to childrengiving these faceless migrant workers an identity and social inclusion by providing id cards and ration cards will go a long way in mitigating their problems shows that debt status is the highest among all the laborers this indicates that there was no improvement in their socio economic status post migration as they couldnt avail the governments housing scheme as none of them had ration cards due to their migratory status limitation the main limitation was due to the shortage of time many more samples couldnt be collected to make the study more diverse suggestions 1to apply and get aadhar card and ration card so as to avail government benefits and schemes 2 to avail the pradhan mantri jeevan jyoti bheema to use the financial schemes of government 3to extend the pradhan mantri suraksha bhima yojana an insurance scheme of the government which covers accidents and sudden loss of life to all construction workers conclusion to conclude bringing out more rural projects which will ensure employment in rural areas such as pmjry to usher in better employment schemes in rural areas will bring down rural urban migration to a certain level

the unfortunate socioeconomic conditions of women workers on construction sites in major cities have become far worse than previously thought and seenthis was corroborated by the field survey conducted in construction sites of bangalore citythe construction sites taken for survey were the new multi storeyed buildings from bangalore mysore road kengeri and ullalupanagara koramangala and jp nagarfor this study 150 samples of migrant women workers were collectedthe other factor was all of them were from scheduled castes the rationale behind the study was firstly to find out if their conditions have improved post pandemic and secondly to understand how farthe government schemes and welfare boards have served their purpose has all these social security measures alleviated their problems to a certain extentnor not the main objective were to find out if their socio economic status changed after migration and to find out if there was any possibility to avail help from the government schemes other than pradhan mantri jeevan jyoti bhima yojane and prsdhan mantri suraksha bhima yojana or get help from ngos research gap showed that there was many shortcomings for these distressed groups as they were sidelined repeatedly but why was it so did they avail of 1 cess meant for construction workers research methodology followed was using both primary and secondary data though it was a primary study descriptive analysis was followed simple random sampling was carried out and percentage method was used for data analysis the findings indicated that most of the time they were not paid the full amount often fell sick besides there was no prevention for the on site accidents and no immediate medical help was forth coming conclusion showed that this problem of distress migration arose because of severe drought conditions in many north karnataka states and their inability to work as agricultural labourers as big farmers preferred to use tractors socially and economically they were a totally repressed lot and suffered more post pandemic in their quest to sustain themselves and their families

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introduction doctors health behaviour appears to affect patients attitudes and their motivation to make lifestyle changes 1 2 3 like their patients however some family doctors use tobacco alcohol and other addictive drugs this could put themselves their practices and the health of the general population at risk as such private problems may become a wider social problem 4 5 6 health behaviours among doctors are a marker of how harmful lifestyle behaviours are perceived in society 7 in several developed countries for example smoking among physicians has decreased dramatically historically physicians started smoking earlier because of their higher socioeconomic status however when it became clear that smoking is harmful physicians gave up smoking at a higher rate than the general population 7 8 9 in contrast with tobacco use many people do not perceive alcohol consumption to be harmful 10 this may be due to the assumption that regular consumption of a small quantity of alcohol may protect against cardiovascular disease 10 11 physicians consume more alcohol than the general population 12 and it has been suggested that the use of opiates and benzodiazepines is five times higher in health professionals than the general public which could be a result of gps familiarity with and access to these types of drugs 13 14 recreational use of drugs such as marijuana and cocaine is less common among doctors than among the general public 14 the prevalence of drug and alcohol misuse in health professionals is approximately equal to that of the general public 12 in flanders prevalence data on current smoking drinking and drug use among gps are unknown this study aimed to determine smoking status drinking habits and drug use among primary care physicians independent determinants of smoking and hazardous drinking were sought and gps were asked about their attitudes toward a healthy lifestyle method participants and data collection an online questionnaire that could be disseminated to gps was created and emailed to flemish gps between 1 april and 31 may 2011 participation was voluntary and anonymous the website of the flemish society of gps and the interuniversity centre for family doctors provided the electronic contact details of gps and gps in training who were active in 2011 participating doctors were encouraged to forward the survey to their gp colleagues questionnaire a cover letter accompanying the questionnaire stated that the purpose of the survey was to know more about substance use by family doctors in flanders the fact that study participation was anonymous was emphasised in the introductory email doctors received a password that gave them access to the survey the questionnaire was created using an aim to estimate the prevalence of smoking alcohol and substance use among gps in order to determine factors that influence these habits and to elucidate gps attitudes toward a healthy lifestyle design and setting online surveybased study in flanders belgium method sociodemographic data and individual risk behaviour were collected by an anonymous selfadministered questionnaire gps and family doctors in training were sent an email request between 1 april and 31 may 2011 results of 626 responders 57 were male the mean age was 45 years eight per cent were current smokers independent risk factors for smoking were working alone hazardous alcohol consumption and smoking cannabis fourteen per cent consumed alcohol daily and 12 admitted at least one episode of binge drinking per month being male cigarette smoking cannabis use and long working hours were associated with an increased likelihood of hazardous drinking sixteen per cent had used sleeping pills and 12 had used minor opiates as painkillers in the year before the study twothirds of gps said they would be reluctant to seek medical help if they were misusing drugs or alcohol conclusion smoking is uncommon in flemish gps in contrast alcohol consumption is high gps who misuse substances will not seek help readily keywords alcohol use general practitioner smoking substance use tobacco use freya saeys and hendrik cammu online tool and included questions on • gps demographics • tobacco alcohol and substance use • attitudes about being a role model • advising patients to stop smoking • the legal smoking ban in public places • the zerotolerance policy for alcohol in traffic and • the willingness to seek medical help should the gp be misusing substances the time to conduct the survey was approximately 5 minutes screening for heavy drinking is very sensitive 15 reliable information about alcohol consumption is only likely to be obtained if appropriate survey methods are used alcohol use and hazardous drinking were measured using the alcohol use disorder identification testconsumption this comprises the first three questions of the world health organizations audit concerning frequency and the amount of alcohol used as well as the frequency of binge drinking each question was scored 04 giving a possible summary score of 012 a score of ≥5 was used as an indicator of hazardous drinking as recommended by the institute of health and society newcastle university uk 16 hazardous drinking is defined as a pattern of alcohol consumption that increases the risk of harmful consequences for either the user or others 17 statistical analysis prevalence of smoking and drinking behaviours along with the use of drugs among gps were calculated using frequency tables some of the variables were categorised categorical differences were tested using pearsons c 2 test for the purpose of logistic analysis the variables age sex working alone children hours worked per week smoking status hazardous drinking status use of cannabis use of psychotropic medication and use of minor opiates were dichotomised the same model of covariables was used for smoking and hazardous drinking a multivariate stepwise logistic regression was assessed statistical significance was set at p 005 analysis and statistical processing of the results was performed using spss results how this fits in data on substance misuse in gps are scant and show mixed results this is the first time to the authors knowledge that smoking drinking habits and substance use have been studied simultaneously in gps compared with the general population gps smoke less and drink more gps would be reluctant or find it difficult to seek medical help if they were misusing drugs or alcohol and this may influence the quality of care for their patients significantly from their female counterparts smoking behaviour table 2 shows that most gps had never smoked and that male gps were more frequently former and current smokers compared with their female colleagues of the 50 gps who smoked at the time of the survey 25 did so daily of these six smoked 10 cigarettes 17 smoked 1020 cigarettes and two smoked 20 cigarettes per day eighteen daily smokers had already tried to stop for health reasons andor to set a good example as a family doctor the same reasons for quitting were given by former smokers smokers were more frequently male single and worked alone hazardous drinking and binge drinking more than once a month occurred more frequently in smokers than in those who had never smoked cannabis use was exclusively attributed to current andor former smokers in a multivariate logistic regression analysis current smokers more frequently worked alone drank hazardously and used cannabis than those who had never smoked drinking behaviour fourteen per cent of responders consumed alcohol daily and 12 admitted at least one episode of binge drinking per month compared with male gps female gps drank less often drank smaller amounts and were less prone to binge and hazardous drinking table 4 summarises alcohol use and levels of hazardous drinking among flemish gps almost all gps drank alcohol in the year prior to completing the questionnaire regular drinkers were defined as those people who consumed 12 glasses per occasion and did so 24 times a month or 23 times a week binge drinking occurred in almost half the responders although for most of those this was not on a regular basis onethird of gps could be considered a hazardous drinker based on their auditc scores hazardous drinking occurred most frequently in younger male gps independent determinants of hazardous drinking were being a male not working alone working 60 hours a week being a current smoker or using cannabis substance use in total 128 gps said they had used psychotropic medication in the year prior to completing the questionnaire sleeping pills were most popular followed by anxiolytics and antidepressants of all 626 gps 16 used sleeping pills 12 minor opiates 5 anxiolytics and 4 antidepressants only three male doctors had used major opiates in the year prior to completing the questionnaire six male and three female doctors stated that they had used amphetamines cocaine ecstasy or methylfenidate there was no association between psychotropic medication use and smoking or psychotropic medication use and hazardous drinking or cannabis use however there was a significant association with opiate use cannabis was exclusively used by gps aged 34 years cannabis users were significantly more likely to be smokers and problem drinkers habits towards a healthy lifestyle almost all gps believed they should be role models for patients and society however 64 stated they would find it difficult to seek help if they thought they had a problem with excessive alcohol andor drug use the majority of gps asked patients about their tobacco use and advised them to stop smoking since 2011 there has been an e666 british journal of general practice october 2014 overall smoking ban in bars and restaurants in belgium 83 of gps supported this measure however significantly more nonsmokers than exsmokers or current smokers supported the current smoking ban the proposed legislative amendment for stricter alcohol control while driving was not well received only 28 of responders supported this draft legislation significantly fewer doctors who drank hazardously agreed than nonhazardous drinkers comparison with the general population the prevalence of smoking drinking and illegal drug use among the flemish general population is based on the belgian health survey of 2008 19 a positive current smoking status was three times more common among the general population than among gps and a greater proportion of gps tried to quit smoking than the general population however only 5 of the gps had not drunk alcohol in the year prior to completing the questionnaire compared with 18 in the general population cannabis consumption in the year prior to completing the questionnaire was almost identical in gps and the general population the use of amphetamines cocaine ecstasy or methylfenidate was generally low in both gps and the general population discussion summary compared with the general population cigarette smoking and the smoking of cannabis is less prevalent in gps however gps drink alcohol more frequently those working alone are more likely to be smokers a possible explanation is that they are often male older and started working in an era when smoking was pervasive peer pressure in group practice may stifle smoking habits sooner hazardous alcohol andor cannabis use are also related to smoking nearly all responders said they drink alcohol on a regular basis and at a moderate level hazardous drinking occurred in onethird of the studied population male sex and younger age were associated with this in the present study results showed that long working hours increased the risk of hazardous drinking sleeping pills and minor opiates were the most frequently used selfprescribed drugs cannabis was only used by gps aged 34 years while amphetamines cocaine ecstasy or methylfenidate were consumed rarely the majority of gps reported seeing themselves as role models for their patients twothirds of responders said it would be difficult or they would be reluctant to seek help if they were misusing substances strengths and limitations the main strength of this study is that to the authors knowledge it is the first to investigate simultaneously the prevalence data were collected via an online selfadministered questionnaire this method is susceptible to errors such as responders desire to give socially acceptable answers an underreporting of alcohol consumption by 4060 is not unusual 20 taking this into consideration the volume of alcohol consumption may be much greater in reality it was not possible to determine the exact response rate to the survey because gps were encouraged to forward the questionnaire to their gp colleagues this is an important shortcoming in addition response bias must be taken into consideration however it should also be noted that the reverse is also possible in an anonymous questionnaire responders may often give more genuine answers to sensitive questions than they would if they were identifiable another limitation is that a large proportion of responders were young physicians in training who may have influenced the overall data for example young doctors were the only ones who smoked cannabis the study compared prevalence data from the doctors with prevalence data conducted from a study in 2008 in the general population more recent data were not available this comparison should therefore be interpreted with caution a strength of the study is that the auditc tool was used because of its brevity and clarity this has been thoroughly validated and is widely used 21 comparison with existing literature there is a strong link between the use of tobacco and the use of alcohol andor cannabis 22 the smoking prevalence among physicians is reported to be 10 in the us scandinavian countries the netherlands the uk and australia 23 a review from the literature found high alcohol consumption prevalence rates among doctors 12 long working hours increased the risk of hazardous drinking this could be due to fatigue and work stress factors leading to job dissatisfaction 24 25 or burnout 26 a 2010 report showed that younger norwegian and german doctors have lower rates than older doctors of binge and hazardous drinking 27 the amphetamine and cannabis use in this study is in line with us data 28 as in flanders sleeping pills and minor opiates were the most frequently used selfprescribed drugs by us doctors 14 a belgian survey of 1500 medical specialists of all kinds 29 based on the research model showed comparable results with respect to smoking prevalence and drinking habits specialists were more likely to drink alcohol on a daily basis compared with gps and used anxiolytics more often implications for research and practice more research needs to be conducted on alcohol prevention in physicians with the help of reliable data such as these better ways of planning preventive and interventional strategies for doctors with problems could be implemented to build a good care system for doctors it is important to know which group is the most vulnerable and which factors influence an unhealthy lifestyle countries such as the uk canada and australia are developing programmes to identify and treat physicians whose performance is impaired or who are disruptive and some healthcare organisations are targeting prevention and promoting wellness 30 it would be of great significance if belgian policymakers with the aid of physicians should not only promote healthy behaviour in patients but in doctors as well coping strategies and stress management should be incorporated in medical training every doctor should have a family doctor trained to take care of colleagues with psychological or substancemisuse problems by doing so a solid and wellstructured healthcare system for doctors could be created it is very difficult when a doctor becomes a patient indeed patients consider doctors as role models for a healthy lifestyle 31 however it has previously been reported that doctors have problems coping with their own physical and psychological weaknesses 32 which may also prevent them from seeking help when they need it ethical approval the study protocol was approved by the medical ethics committee of the university hospital brussels provenance freely submitted externally peer reviewed competing interests the authors have declared no competing interests

patients often consider health professionals to be role models for leading a healthy lifestyle but no data is available on tobacco alcohol or substance use among gps in flanders northern belgium

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introduction over the first weeks of social isolation during the covid19 pandemic in spring 2020 people typically reported that time had passed differently in this new situationfaster for some but more slowly for others this remarkable change in subjective time after a few weeks of social isolation was reported as significant time distortions in many newspapers around the world 1 timeperception researchers worldwide responded quickly and conducted online studies to assess potential changes in the experience of time during this crisis in an italian study 1310 individuals aged between 18 and 35 were asked to compare their experience during the first week of the lockdown with the week before the lockdown when they still had a regular life 2 participants reported pronounced problems with keeping track of time ie they were often confused about what time of the day or what day of the week it was they also reported an expansion of time and this feeling was positively related with the sense of boredom in two subsequent studies conducted in the uk participants were asked how quickly the previous day and week had passed as compared to the time before the lockdown 34 the first study with 603 participants assessed the experience between 14 and 38 days after the beginning of the lockdown about 80 of participants reported unusual changes in their experience of time with a split into two subgroups one reported experiences of the previous dayweek as having passed slower and one as it having passed faster compared to before the pandemic the second uk study 4 assessed experiences during the second lockdown 8 months later 80 of the participants again reported a change in the experienced duration for the previous week or day compared to normal with a majority of participants rating the eight months since the beginning of the pandemic as having passed slower than usual in both uk studies two main factors were identified which determined the felt passage of time people who had increased stress levels and less satisfaction with their social situations judged time as having felt longer while people who had lower stress levels and were more satisfied with their social situations reported intervals as shorter than before the pandemic two french studies collected data during the first lockdown in march and april 2020 by assessing passage of time judgments ie what are your feelings about the speed of the passage of time 56 french participants characterized the time during the lockdown as an extreme increase in boredom and sadness both of these feelings were related to the impression that time had passed more slowly during the lockdown compared to before the lockdown the variable lack of activity appeared to reliably explain the feeling of time slowing down followups of these two studies 6 and 12 months later showed that this impression of a deceleration of time passage and its association with feelings of boredom and depression persisted 7 in a longitudinal brazilian study 8 with 3855 participants the first assessment was undertaken 60 days after socialisolation measures had beein introduced weekly assessments of time awareness followed for 14 weeks during the pandemic this longitudinal design enabled researchers to show how brazilians initially perceived an expansion of time which steadily decreased over the course of the following weeks complementing the european studies a subjective expansion of time was related to negative emotions such as loneliness a study in uruguay among university students 9 assessed different measures including the passage of time they reported similar results an association of psychological distress due to covid19 restrictions with a felt slower passage of time a blurred sense of time and more boredom in a recently published longitudinal study from germany this association of boredom as well as deteriorated emotional state with decelerated potjs was confirmed 10 taken together different international studies suggest that the subjective experience of time was perceived as distorted during the covid19 pandemic and the experience of social isolation negative emotions boredom and distress were associated with higher ratings of deceleration andor time dragging while more positive affect satisfaction with the social situation and more routine led to an acceleration of subjective time the experience of time deceleration dominanted these empirical findings during the covid19 pandemic support previous findings linking negative affect to subjectively expanded duration and a slower passage of time 1112 it also supports findings which showed that positive affect combined with social satisfaction led to a subjective acceleration of time passing 13 however none of the studies mentioned compared the data regarding the experience of time during the pandemic to data from preceding nonpandemic periods as many participants in studies judging the passage of time over longer life spans reported time as having passed comparably quickly 14 15 16 the perception of time over long intervals could be generally skewed people might feel that long intervals of time are passing differently compared to earlier periods this implies that the existing studies carried out during the pandemic cannot completely exclude the possibility that their participants would have reported similar levels of distorted time in nonepandemic settings too we therefore decided to gather data applying the exact same measurements namely passageoftime judgments covering the previous year and the previous five years as we had done in earlier studies conducted before the pandemic 1517 to compare these judgments with judgments during the pandemic taken together we applied this intersubject design to investigate whether the reported perception of timedistortion really is a specific pandemic phenomenon given the findings presented in previous studies we derived three concise hypotheses we expected potjs provided during the pandemic to indicate a slower subjective passage of time than before the pandemic we also expected most duration judgments for the time since the beginning of the pandemic to indicate that these were perceived as longer than usual finally we expected that reports of negative affect and lower social satisfaction would be associated with a subjective experience of time passing slower and the respective duration being felt as longer we also inquired about approval of and compliance with the covid19 countermeasures imposed by the german authorities and the plausibility of these measures methods materials perception of time regarding the passage of time participants answered the question when looking back how did the last 12 months pass by for you on a 7point likert scale ranging from very slow to very fast a potj for the previous five years was also assessed to compare whether a potential effect on time experience would compromise potjs even beyond the actual period of the pandemic both measures were used in the exact same manner in our prior studies 1517 we asked participants for their subjective durations for the period since the first lockdown in germany adapting the same questions used by ogden 4 since the beginning of the first lockdown due to the coronavirus here in germany 14 months have passed how long does this period feel participants answered this question on a 5point likert scale ranging from a lot shorter than 14 months rather shorter than 14 months approximately 14 months rather longer than 14 months to a lot longer than 14 months perceived changes in daily life changes in life are typically associated with alterations in the perception of time and previous research during the pandemic provided initial evidence that this also applies here 4 we therefore requested participants to rate changes in their daily lives on seven dimensions routine fear for ones own as well as the health of close persons stresslevels at home and at work fatigue and worries regarding ones livelihood compared to before the pandemic participants answered these questions on 5point likert scales ranging from the level is essentially lower to essentially higher both fearand both stressitems were combined into one composite score for analyses with an acceptable cronbachs α 70 for changes in fear for health and cronbachs α 57 for changes in stress levels affective states since recent study results suggest effects of affective states on time estimates during the pandemic we assessed several affective judgments and experiences that seem relevant regarding the experience of time during the pandemic subjects were requested to indicate their respective average levels during the pandemic compared to before the pandemic by responding on 5point likert scales ranging from a lot less to a lot more we also addressed the level of satisfaction with social life during the pandemic with one item used by ogden 4 how satisfied are you with your social life during the pandemic participants responded to this question on a 5point likert scale with higher scores indicating higher satisfaction all items were then included in an exploratory and factor analysis with a kmoindex of 80 and a significant bartletts test of sphericity χ2 119525 p 0001 this suggests that the sample was suitable for a factor analysis 20 after varimax rotation two factors were extracted with a lowest factor loading of 60 factor loadings are displayed in table 1 the coherency of content indicated that these two factors seem to mirror two different affective patterns the first factor subsuming a rather depressive and lonely combination of affective states and the second factor a rather negative agitatedaggressive combination as these factors appeared to depict patterns and not consistent scales the values were zstandardized and added up resulting in two sum scores approval of countermeasures we asked participants three questions about their level of approval of the covid19countermeasures introduced by the german authorities acceptance of measures compliance with measures and plausibility of measures all answered on 7point likert scales with higher values indicating higher levels of agreement a composite score was calculated with a very good cronbachs α 081 procedure the survey was conducted on soscisurvey 21 and started with information regarding protection of privacy and about the study stating that subjects would be asked to report their experience of time and its changes in the recent past after providing informed consent by ticking a checkbox the actual survey started with the potj for the preceding year on the next page we assessed the the dj for the preceding 14 months the time since the beginning of the pandemic in germany the potj for the preceding five years was inserted on the subsequent page followed by one item asking about life satisfaction questions regarding the level of approval of countermeasures were asked afterwards we finally requested demographic data including the number of coresidents number of children living in the same household population of hometown occupational status and formal education preregistration and ethics this study was conducted in accordance with the declaration of helsinki and the ethics guidelines of the university of regensburg these types of psychological studies of do not require the ethical approval of an ethics committee in germany participants were informed about the aim of the study and gave informed consent regarding the use of the data by clicking a checkbox this was conducted in accordance with the german dsvgolegislation the studys main hypothesis was preregistered using the open science framework all data exclusions measured variables and the complete procedure were reported 22 both data and code of the reported analyses can be accessed via an online repository on osf statistical analyses the statistical data analyses were conducted with spss 1 pearson productmoment correlations were calculated for correlational analyses three multiple regressions were performed with the forcedentry method to analyse predictors of potjs djs and approval of countermeasures for potjs and djs living alone as a potentially relevant demographic variable changes in levels of fear for health changes in stress levels due to changes in routines changes in fatigue and worries regarding livelihood were entered in a first step and the two emotionalreaction patterns in the second step in the third regression with compliance as an outcome variable the three demographic variables education level living alone and population of hometown were included in a first step these were followed by changes in routine and stress and fear levels in a second step time estimates in a third step and the emotionalreaction pattern in a fourth step bootstrapping was applied in all models due to violations of assumptions 23 the 14 previous months had lasted subjectively like a typical 14month period 556 felt that these 14 months had seemed a lot or somewhat shorter than usual 352 reported that the these 14 months had seemed a lot longer or somewhat longer than usual results passage table 2 shows pearson correlation coefficients for the relationships between both subjective duration and the potjs for the preceding year and measures of satisfaction with social life emotions and routinestressworries a subjectively longer dj for the preceding 14 months was related to less satisfaction with social life more boredom more sadness less emotional satisfaction less relaxation higher levels of anger and more fatigue faster potjs for the last 12 months were reported by participants who were more satisfied with their social lives fear for ones own health and for the health of close friends and relatives were the only emotional variables that were not associatied with any of the two measures for the subjective experience of time however these two variables were clearly associated the three measurements regarding approval with the covid19 countermeasures introduced in germany namely acceptance compliance and plausibility additionally higher levels of anger were clearly associated with less acceptance of less compliance with and less perceived plausibility of these countermeasures results of the twolevel regression analysis for djs are displayed in table 4 the complete second model which produced the better fit explained 76 of the variance f 610 p 001 the coefficient for changes in daily routines indicates that higher levels of daily routine led to shortened djs high values in both affective patterns predicted a perceived extension of djs the coefficient for fatigue was no longer significant in the second model after inclusion of the affective patterns the twolevel regression analysis for the potjs was not significant f 177 p 103 implying that our chosen predictors had no influence on the outcome variable namely the potjs for the preceding 14 months the analysis of the fourlevel regression for approval of countermeasures revealed two significant models the second f 800 p 001 and the fourth model f 625 p 001 the fourth model explained the largest amount of variance corrected r 2 11 as can be seen in table 5 which depicts both significant models while the time estimates had no impact on the outcome variable fear of infection predicted higher compliance and worries regarding livelihood predicted lower compliance the coefficient for changes in daily stress levels was no longer significant when the affective patterns were included in the model lower levels of the agitatedaggressive pattern predicted higher levels of approval of the countermeasures in the fourth model the coefficient for fatigue also came close to the threshold of significance discussion this study which investigated time perception during the pandemic in germany led to several results in may 2021 people reported the previous year as having passed markedly slower than people asked before the pandemic the experienced duration of the previous 14 months following the start of the pandemic showed a bimodal distribution with a majority of participants rating these to have seemed relatively shorter a minority of participants rated these as relatively longer ie people were somewhat split in their judgments of experienced duration the experience of time having passed fast during the previous year was mirrored by a rating indicating a shortened perception of the 14month time interval both negative affective patterns depressivelonely and agitatedaggressive predicted the djs in the way that high levels of negativity and increased fatigue led to a felt extension of time regardless of all plevels have been adjusted to correct for alphaerror inflation using the benjaminihochberg falsediscovery rate 24 with an online tool by hemmerich 25 activation levels a perceived shortening of duration was associated with a perceived increase in routine regarding the governmental countermeasures the more people feared for their health and the health of people close to them the more they approved of the countermeasures the agitatedaggressive affective pattern and worries regarding livelihood were associated with lower levels of approval of countermeasures our main result is that changes in the perceived passage of time during the pandemic as concluded by many authors in several studies from different countries can be confirmed even when comparing the passage of the previous year to a baseline the previous year was generally judged as having passed markedly slower by participants who provided their judgments during the pandemic compared to participants who made these judgments before the pandemic this corresponds with results from a uk study where almost 40 of the participants reported the time since the beginning of the pandemic as longer than a normal 8month period 4 the duration of the previous 14 months revealed a split pattern with relatively more participants reporting time having shortened during the pandemic while fewer people reported these 14 months as having felt longer than a normal 14month period this is almost exactly opposite to the pattern found in the uk 4 where 54 of the participants rated the time since the beginning of the pandemic as subjectively longer and only 29 as shorter than a typical 8month period this difference in the response patterns could have been caused by different public responses to the pandemic but it might also reflect a methodological artefact in all plevels have been adjusted to correct for alphaerrorinflation using the benjaminihochbergfalsediscoveryrate 24 with an online tool by hemmerich 25 the ukstudy participants were first asked to rate the duration of the previous day and the previous week in both questions participants were explicitly requested to rate their experience of time passing in comparison with normal 4 p 6 although this comparison was not addressed in the question regarding the preceding eight months it seems likely that participants compared these eight months with the same interval before the pandemic in our study an explicit comparison with the same interval before the pandemic was never requested thus many more people judged the interval as relatively shortin line with the potjsbut a relatively large number of responses indicated a prolonged time experience in fact the substantial association between pojts and djs for the intervals covered by the pandemic suggests that both measures are relatively equal concerning retrospective judgments for these long intervals this adds support to the finding that potjs and djs for longer intervals starting in the range of several minutes coincide 26 although this relation can not be found under all circumstances 27 by comparing potjs for the last year during the pandemic with potjs from earlier we found compelling support for preexisting evidence regarding the experience of a lenghtened slowed experience of time for the interval following the beginning of the pandemic as compared to earlier times eg 348920 therefore we can exclude the possibility that previous results which reported distorted timeexperiences during the pandemic reflect only the fact that the experience of time for long intervals feels generally skewed for most people regarding potential explanations for this relative deceleration we found that higher levels of emotional negativity predict an experience of time as having passed slower for the preceding 12 months in our german sample when investigating the effects of specific emotions high boredom and low levels of social satisfaction contentment and relaxation had the highest associations with a perceived deceleration of time high boredom anger and sadness as well as low levels of contentment satisfaction and relaxation were associated with a longer dj these results in particular the association of asubjective deceleration as well as longer duration with negative affect are in line with findings from studies conducted in italy 2 france 5 6 7 the uk 34 brazil 8 uruguay 9 and germany 10 this finding is therefore very robust and largely independent of the cultural backgrounds how can these consistent findings be explained the most common approach to explain differences in retrospective time experience is to link it to experiences of contextual changes in the regarding intervals and the resulting storage size which reflects the quantity and complexity of stored information from the respective interval 1928 according to such memory based approaches intervals filled with multiple and diverse experiences lead to more memory content which results in the impression of time being rich in memories and perceived as long these theories suggest that the experience of time is other than actual sensory experiences approached through the representation of images from the past 29 an idea that was proposed already in the 19 th century by william james routine which implies a life with few changes and therefore potentially few differing memories has been shown to be associated with a faster passage of time for longer time intervals 31 this may offer a plausible explanation for the pandemic situation where due to lockdowns and socialdistancing measures the diversity in possible activities and life events was heavily restricted potentially leading to fewer accessible memories following these deliberations the time since the beginning of the pandemic should have been perceived as having shortenedpassed faster than usual for most people this was indeed often reported in the media relatively early in the pandemic see 1 however our data as well as the preceding studies revealed a different picture with a notable tendency towards a relative deceleration of time passage compared to before the pandemic at the same time and similar to results provided by ogden 4 we found an association between routine in daily life and the experienced duration but only for the measure targeting experienced duration not for potjs and this correlation is very small this seems plausible given recent findings that found no support for an association between life events andor important memories with potjs for intervals spanning over several years 32 patterns of negative affect have proven to be better predictors for the experience of time in both our and preceding studies before the pandemic only few studies were conducted that investigated the interplay between affect and the experienced time over longer intervals eg in the range of many minutes in these studies depression which is by definition associated with low levels of wellbeing 33 is clearly linked to a perceived deceleration of time additionally some studies that investigated shorter intervals in the range of seconds provided evidence showing that intervals filled with unpleasant stimuli are perceived as longer or that people in negative affective states have an extended experience of time another interesting association comes from previous studies investigating the interplay between emotion and waiting these show that negative emotions experienced while waiting lead to an overestimation of the waiting period 3637 while positive affect is linked to the experience of accelerated time these results suggest that affect matters for retrospective judgments of the experience of time in contrast for prospective time experience the association between attention allocation and time experience has been repeatedly discussed and theories postulated that aligning attention towards time leads to an extension of the subjective experience of time 38 the consistent results of positive affect being associated with experienced faster time passageshorter time experience and vice versa for negative affect might suggest that a similar mechanism is also at work here people probably focus more often on time and wish for it to pass during an interval associated with high levels of negative affect and aversive states in such situations time drags and feels as if it were passing too slowly during relatively more pleasant situations there is no craving for time to pass faster since one is occupied with absorbing activities thus the split result regarding the duration of the time since the beginning of the pandemic could reflect that some people experienced time as dragging while others were able to adapt better and experienced the situation as less aversive or even partially positive which results in time experienced as shorter than usual note that most adults consistently rate long intervals ranging from a day up to several years as having passed quickly under usual circumstances eg 143916 these deliberations are still tentative because to the best of our knowledge concise theories explaining an association between low wellbeing negative affect and a deceleration in subjective time for retrospective judgments over long intervals in the range of months and years are missing to date a more elaborated explanation of these findings is a matter for future research we can presently only conclude that our study in line with previous ones highlights that the pandemic has led to a relative deceleration of the subjective experience of time and that the experience of time during the pandemic was markedly associated with social satisfaction and the affect people have reported for the time since the beginning of the pandemic additionally it is worth noting that our regressionmodels for the djs explained only a small proportion of variance despite a relatively large sample size this implicates that there are many other factors which potentially impact ratings of timeexperience although we tried to capture some variables which address lifecircumstances and the respective changes during the pandemic our study did not target these in depth it seems for example likely that higher demands in childcare and the resulting increases in workload might have led to variations in the experience of time and disparities between men and women since numerous studies revealed that the decrease in childcare at home due to the discontinuation of childcare facilities and schools during the pandemic was largely shouldered by women this seems relevant for the experience of time since previous research also revealed that parents report a faster passage of time compared to adults without children 43 one might also argue that items such as worries regarding ones livelihood depict underlying phenomena only on a shallow level since such worries could be relatively independent of an existential dimension which in turn might be associated with factors having a potential impact on the experience of time however these items were included in our study in order to detect potential domains that might have relevance for the experience of time potential associations uncovered here might serve as starting points for future research which targets the interplay of demographical and situational factors with the experience of time in depth among our regressionmodels an exploratory analysis for predicting approval of the covid19 countermeasures introduced by the german authorities led to the highest proportion of explained variance with this analysis we confirmed previous findings that high levels of fear for health were associated with higher reports of compliance plausibility and agreement with the restrictions in other countries 4445 in contrast participants who felt their livelihoods threatened reported lower levels of approval with the measures this emphasizes the importance of specific fears and worries for approval of restrictions and countermeasures during a pandemic governmental policies should point out the danger posed by a virus during a pandemic but also address worries of the security of livelihoods because both influence approval of the countermeasures our second finding showed that approval of countermeasures was also associated with higher levels of agitatedaggressive affects this complements previous theories predicting compliance with countermeasures which focus on the effects of rather stable variables such as demographics personality or trust in science 47 and goverments 48 our study results amend these findings with an affectivestate component summed up our study provides a number of important findings corresponding with previous research we found a relative deceleration of experienced time during the pandemic notably we demonstrated this by directly comparing potjratings from during the pandemic to ratings from before the pandemic our data also supports previous findings showing that an extended time perception was linked to negative affect a subset of negative affect namely negativeaggressive emotions was clearly linked to less approval of the governmental countermeasures introduced to overcome the pandemic while healthrelated fear predicts higher levels of approval of these measures the data and analyses can be accessed via an online repository on osf

several covid19 studies on the felt passage of time have been conducted due to the strong feeling of time distortion many people have experienced during the pandemic overall a relative decelaration of time passage was generally associated with negative affect and social isolation a relative acceleration was associated with an increase in routine in daily life there is some variability in results depending on the country of study and covid19 restrictions introduced participants demographics and questionnaire items applied here we present a study conducted in may 2021 in germany including n 500 participants to assess time perception emotional reactions and attitudes towards the countermeasures the passage of time judgments potj for the preceding 12 months during the pandemic were compared to data addressing the same question posed in previous studies conducted before the outbreak of covid19 the previous year was rated as having passed relatively slower during the pandemic compared to the ratings from before the pandemic the duration judgments dj of the 14 months since the start of the pandemic showed a bimodal distribution with both relatively shorter and relatively longer djs higher levels of several negative emotions as well as less social satisfaction were associated with prolonged djs and partially slower potjs fear for health was not linked with the subjective experience of time but exploratory analyses suggested that higher levels of fear were linked to more positive evaluations and approval of the governmental countermeasures those who reported higher levels of negative agitatedaggressive emotions showed lower levels of consent with these measures

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the prevalent use of computers and the internet has significantly and globally changed the way people work and live it is estimated that the number of internet users worldwide is around 466 billion and in saudi arabia this number is forecast to reach 3622 million in 2025 on the negative side of this phenomenon some people are prone to selfdamaging behavior known as internet addiction ia can be defined as a compulsive need to spend an excessive amount of time on the internet to the extent that other aspects of life are allowed to suffer li et al cited as symptoms of ia a preoccupation with and psychological dependency on internet activities and use of the internet to cope with negative emotions and reduce stress beard and wolf indicated as symptoms increasing amounts of time online necessary to reach satiation and unsuccessful attempts to decrease usage and asserted that symptoms of ia overlap with dsmiv criteria for diagnosing other addictions such as pathological gambling a view shared by others research has shown that adolescents are at the forefront of internet addiction risk adolescents use the internet for many legitimate positive and beneficial reasons such as informationsearching schoolwork music and video entertainment and appropriate use of social media the internet is appealing to adolescents because it offers a social milieu in which to interact with others and build relationships however some adolescents particularly stressed individuals cross the line from positive internet use to overuse and addiction and there is abundant literature detailing the deleterious effects of internet addiction on adolescents in particular for example yavuz found that internet addiction negatively affects adolescents levels of happiness cerutti et al found that higher levels of internet use by adolescents were associated with depression and other emotional and behavioral problems kumar et al also found that negative impacts of ia among 11 th and 12 th grade students include emotional and behavioral difficulties as well as hyperactivity tsitsika et al determined that ia in adolescents led to poor academic performance as well as engagement in risky behaviors lam et al found that internet addiction increases the risk of selfharm among adolescents in sum internet addiction is a serious public health problem among adolescents and it is important to investigate factors associated with it the family environment plays an important role in the establishment of adolescents social interactions and behavior the benefits of assessing family functioning derive from the fact that the family is an extremely important element in the physical social and psychological development and maintenance of the wellbeing of its members the circumplex model describes family functioning to be a function of family cohesion and flexibility or adaptability family cohesion refers to the emotional connection or bonding that family members experience towards one another while family adaptability is the capability of a family to adjust its authority or power structure roles and relationships in addressing the developmental and situational issues that can occur in families balanced levels of cohesion and flexibility are most conducive to healthy family functioning conversely unbalanced levels of cohesion and flexibility are associated with problematic family functioning previous studies have reported that lower levels of family functioning lower family cohesion and divorced parents and conflicted families are related to the emergence of internet addiction whereas positive parenting and family functioning such as high levels of communication can play preventative roles with respect to ia a review of the literature concluded also that young people with internet addiction were more likely to come from dysfunctional families compared to those without internet addiction a number of previous studies have shown that deviant peer affiliation influences internet addiction and is related to family functions it has also been reported that children from families with poor family functioning were more likely to be members of deviant peer groups therefore it is plausible that the relationship between family functioning and internet addiction may be impacted by deviant peer affiliation xin et al argued that adolescents peer relationships at school seem to be a crucial contributor to ia peers are major components of social interaction that influence many aspects of mental and intellectual development during adolescence associating with inappropriate friends is one of the most important links to crime and substance use and an increase in deviant behaviors in general it has been shown that adolescents peer discussions of criminal or illegal activities is related to delinquency violence substance use risky behaviors and behavioral problems as well as inappropriate use of the internet while previous studies have investigated the role of deviant peer affiliation in the formation of internet addiction no such studies have been conducted in the context of saudi arabian adolescents for example in a sample of chinese adolescents li et al found that deviant peer affiliation mediated the relationship between school connectedness and internet addiction similarly jia et al reported on the mediating role of deviant peer affiliation in the association between studentteacher relationship and internet addiction in another study the relationship between perceived school climate and internet addiction was mediated by deviant peer affiliation among adolescents the identification of the mediating paths that operate between adolescents family functions deviant peer affiliation and internet addiction is crucial in order to develop preventive strategies to inhibit ia among adolescents however such mediating factors are still unknown as previous research has not highlighted these underlying mediating mechanisms moreover no studies have investigated the associations between family functions deviant peer affiliation and internet addiction in saudi arabia therefore this study aimed to examine the association between both family cohesion and adaptability and internet addiction and whether this association is mediated by deviant peer affiliation among adolescents figure 1 summarizes this conceptual framework methods participants and data collection saudi adolescents were recruited to take part in this study the sample was obtained using convenience and snowball sampling the study was conducted during the covid19 pandemic so it was conducted online the adolescents were contacted through schools and schools were chosen from the metropolitan areas of saudi arabia the resultant sample of 946 adolescents had a mean age of 185 years participants were informed about the design and purpose of the study and provided consent for participants under 18 years old consent was also dependent on gaining appropriate permissions from school boards and 1 3 parents participants completed questionnaires during regular classroom hours participation was voluntary and participants were allowed to withdraw from the study at any time ethical approval for this study was provided by king abdulaziz university in saudi arabia measures participant questionnaires included sociodemographic characteristics questions the internet addiction test the deviant peer addiction instrument and the family adaptability and cohesion scale third version this measure consists of 20 items designed to measure the presence and intensity of ia in respondents items are scored on a fivepoint likert scale ranging from 1 to 5 thus the total score for the internet addiction test ranges from 20 to 100 this instrument had a sufficient internal consistency reliability the internet addiction test the deviant peer affiliation instrument this measure contains 12 items using a fivepoint likert scale for each item ranging between 1 and 5 respondents are asked how many of their close friends engaged in conduct such as stealing smoking cheating and other deviant behaviors the minimum total score is 12 and the maximum is 60 the scale had an adequate internal consistency reliability the family adaptability and cohesion scale third version this measure consists of 20 items of which 10 oddnumbered items measure family cohesion and 10 evennumbered items measure family adaptability it also uses a fivepoint likert scale for each item ranging between 1 and 5 in this study the scale had a sufficient internal consistency following olson linear scores were computed and used for family cohesion and family adaptability respectively and the scores range from 1 to 8 for both constructs data analysis the rstudio software package was used for data management and analysis descriptive statistics were analyzed first differences in internet addiction were estimated using kruskalwallis tests since the data were not normally distributed correlation analyses were also calculated on the whole sample but separately for females and males then a set of structural equation models was estimated to test the potential mediation roles of deviant peer affiliation in the relationship between both family cohesion and family adaptability and internet addiction since the data were not multivariate normal we used the wlsmv estimator which does not assume normality when the sample size is large several fit indices were used to compare models including chisquare root mean square error of approximation standardized root mean squared residual comparative fit index and tuckerlewis index results the sociodemographic characteristics and the results of the kruskalwallis tests are summarized in table 1 around 63 of the sample were females 19 were middle school students 42 were high school students and 39 were university students twentynine percent had fathers with less than high school education 24 had fathers with high school education 36 had fathers with a university degree and 11 had fathers with masters or doctoral degrees 342 of the participants had mothers with less than high school education 247 had mothers with high school education 3265 had mothers with a university degree and 85 had mothers with a masters or doctoral degree in terms of monthly income 391 were from families with less than sr 5000 241 were from families with monthly incomes from sr 5000 to sr 9999 163 were from families with monthly incomes from sr 10000 to sr 14999 and 205 were from families with monthly income greater than sr 15000 as indicated by the kruskalwallis tests significant differences were found in internet addiction based on gender where males had increased ia scores based on fathers education where those whose fathers education was less than high school had higher scores on mothers education where those whose mother had a university degree reported increased scores and on income where those from families earning less than sr 5000 per month had increased scores of internet addiction the descriptive statistics pearson correlations and cronbachs alphas are summarized in table 2 the mean score for family cohesion was 333 of a possible maximum score of 8 the average score of family adaptability was 637 also with a maximum of 8 the mean score for deviant peer affiliation was 196 with a possible range between 12 and 60 and the mean score for internet addiction was 583 where scores could range from 20 to 100 internet addiction was correlated with family cohesion family adaptability and deviant peer affiliation in the whole sample the correlation coefficients for females and males separately are displayed in table 3 in males internet addiction had a negative correlation with family cohesion and a positive correlation with family adaptability and with deviant peer affiliation in females internet addiction was negatively correlated with family cohesion and positively correlated with deviant peer affiliation the correlation of internet addiction with family adaptability was negative but not significant in females to test the mediation role of deviant peer affiliation in the relationship between both family cohesion and family adaptability and internet addiction a set of paths 4 in this model deviant peer affiliation mediated the relationship between family cohesion and internet addiction but not the relationship between family adaptability and internet addiction since the path from family adaptability to deviant peer affiliation was not significant in model 2 this nonsignificant path was deleted and the fit indices were improved considerably in this model deviant peer affiliation mediated the relationship between family cohesion and internet addiction and family adaptability was allowed to have a direct relationship with internet addiction model 2 was then taken as the final model and is portrayed in fig 2 which shows the standardized regression coefficients for the direct paths among the constructs table 5 presents the indirect effects using bootstrapping methods as shown in fig 2 the path from deviant peer affiliation to internet addiction was significant the path from family cohesion to deviant peer affiliation was also significant the path from family cohesion to internet addiction was significant as well finally the path from family adaptability to internet addiction was positive and significant as table 5 portrays the indirect effect of family cohesion on internet addiction through deviant peer affiliation was significant indicating that deviant peer affiliation mediated this relationship discussion this study investigated the relationship between the family functions of family cohesion and family adaptability and internet addiction among adolescents and the mediating role of deviant peer affiliation in this relationship several conclusions concerning this relationship can be asserted initially one notable finding was that family cohesion was negatively associated with internet addiction and deviant peer affiliation was positively correlated with adolescents internet addiction this is in accordance with previous studies cited earlier in this papers introduction these findings are also in line with the studies of tian et al and zhu et al who confirmed the relationship between deviant peer affiliation and adolescents internet gaming addiction also confirmed were the results from chung et al that low family cohesion was related to internet addiction in addition deviant peer affiliation mediated the relationship between family cohesion and internet addiction the current study found that family cohesion was negatively correlated with internet addiction but contrary to our expectations there was a positive correlation between family adaptability and internet addiction based on the olson circumplex model family therapists interpret family functioning in terms of family cohesion and adaptability the current study found a negative correlation between family cohesion and internet addiction this supports the findings of salimi and hosseini emphasizing the need to investigate family functions in adolescents dependence on the internet pashaeii et al asserted that an adolescents addiction affects the childs family this implies that when adolescents display internet addictive behaviors this negatively affects family cohesion this confirms the correlation found by balkan and adaher between social cohesion including family relations and the consequences caused by internet addiction the explanation for this negative relationship might be the fact that excessive internet use interferes with family time and prevents adolescents from spending time with adults and when adolescents are from disrupted families they tend to seek attention externally including through social media via the internet as a means of emotional regulation which might lead to dependency on the internet regarding family adaptability which briefly is defined as the ability to adapt to family changes and stressors this study also found that it is positively correlated with internet addiction in the whole sample and in males but no correlation was found in the sample of females it seems that the relationship between family adaptability and internet addiction is different for males and females future research should investigate this in depth the positive relationship found was surprising since yan et al reported that family adaptability was negatively correlated with adolescents internet addiction this suggests that high functioning families that have better parentchild involvement and adapt better in the face of difficult intrafamily relationships are preventative of ia in the children this negative correlation between the two factors was also found by olson et al the mechanisms underlying the positive relationship found in this study between family adaptability and internet addiction are to be addressed by future research family cohesion was also found to negatively correlate with deviant peer affiliation in the whole sample in males and females that is poor family functioning can lead to the familys children forming deviant peer affiliations this is in line with many studies that confirmed such findings for example fergusson horwood reported that children from dysfunctional families were more likely to form deviant peer affiliations dishion et al found that weak family ties can lead young people to engage in risky behaviors with peers conversely gao et al reported that positive family functioning moderated the risk of deviant peer affiliation others have suggested that unity among family members and the family power structure are unique contributions to positive peer affiliation choices of their adolescent children hirschi asserted that adolescents from healthy functioning families with effective communication and positive family relationships seem not to affiliate with deviant peers these factors indicate cohesion within a family and huey et al found that better family functioning was associated with decreased delinquent peer affiliation and behavior in terms of mediation analysis this study found that deviant peer affiliation mediated the relationship between family cohesion and internet addiction while the relationship between family adaptability and internet addiction was not mediated by deviant peer affiliation this finding corroborates those of prior studies that reported the mediational role of deviant peer affiliation it is possible that when adolescents do not have sufficient family support or their basic psychological needs are not being met by the family they seek out and obtain a sense of belonging with peers which may in turn lead them to poor peer affiliation choices and then deviant behaviors including internet addiction 3 with regard to the prevalence of internet addiction in the sample the results indicated that the internet addiction scores were higher in adolescent males than females in those whose fathers had less than high school education in those whose mothers had a university degree and in children of families earning less than sr 5000 per month as compared to their counterparts the findings are in line with prior research that reported a higher prevalence of internet addiction in boys than in girls the results of this study also corroborate those of previous studies that found that family income fathers education and mothers education were related to internet addiction among adolescents there are limitations of this work that should be mentioned first the study used a crosssectional design and no causal effect statements can be made longitudinal designs should be used by future research in order to assume causality second the data were collected with selfreported measures future research should use other methods of data collection including interviews peer reports and behavior observation third the study used convenience sampling methods which are not ideal for generalizability of the findings future research should use random sampling conclusions the present study aimed to examine whether family functions are related to adolescents internet addiction and whether deviant peer affiliation can mediate the association of these two variables it has been noted that deviant peer affiliation mediated the relationship between family functions and adolescents internet addiction in other words deviant peer affiliation is a strong predictor of such addictive behaviors in young people families that do not satisfactorily meet the basic needs of their members seem to lead their adolescent children to attempt to achieve needs satisfaction from peers on the other hand families in which members are emotionally and socially satisfied do not have adolescent children with deviant peer affiliations families with low levels of cohesion result in children relying too heavily on finding friends outside the family and if they make poor choices may result in juvenile delinquency and internet addiction based on the study results suggestions for prevention include the following as healthy family functioning negatively affects abusive behaviors such as internet addiction there should be an emphasis on the family and enhancing family wellbeing in interventional programs programs should be developed to foster harmonious families by enhancing family cohesion and adaptability and incorporate instruction regarding parenting skills to avoid deviant behaviors in the children however as olson notes there is a need for balanced cohesion and adaptability as opposed to extreme highs or lows moreover since deviant peer affiliation is strongly associated with delinquency and addiction deviant peer affiliation must be a main target of interventions in addition interventions and training programs should be schoolbased since adolescents spend much of their time at school data availability the data that support the findings of this study are available from the corresponding author upon reasonable request authors contributions all authors made a substantial direct and intellectual contribution to the work and approved it for publication consent to participate informed consent was obtained from all individual participants included in the study and participation was completely voluntary conflicts of interest the authors have no conflicts of interest to declare that are relevant to the content of this article publishers note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations

the aim of this study was to investigate the mediating role of deviant peer affiliation in the relationship between family functioning specifically family cohesion and family adaptability and internet addiction among saudi adolescents a sample of 946 saudi arabian adolescents with a mean age of 185 years sd 306 was obtained using snowball sampling path analysis using structural equation modeling was conducted the results indicated significant negative relationships between family cohesion and internet addiction and between deviant peer affiliation and family cohesion and a significant positive relationship between family adaptability and internet addiction in accordance with prior research we found a significant positive relationship between deviant peer affiliation and internet addiction but in terms of mediation deviant peer affiliation mediated only the relationship between family cohesion and internet addiction in conclusion it is important for the effectiveness of interventions and preventive programs that aim to address deviant peer affiliation and internet addiction in adolescents to enhance the wellbeing of their family systems

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constructs and behavior intentions are most predictive of behaviors when they are proximate to the context of action and target specific actions insights from cognitive science tra has been widely used in fertility research 1 and has proven useful in many substantive areas 2 however as argued elsewhere recent developments in cognitive science challenge one of its key features most notably the assumption that the formation of conscious intentions to act precede all behaviors 3 we discuss the evidence against this assumption in a later section here we provide necessary background by outlining three major insights drawn from contemporary cognitive science and neuroscience and combining them into a simplified model of cognitive processes in the brain 1 cognition depends on two types of processes in the brainwe label these deliberative and automatic processes 4 deliberative processes include those brain functions that we are most familiar with reasoning making decisions simulating future courses of action and controlling impulses these are largely conscious and correspond to what we think of as rational thought and free will automatic processes in the brain occur outside consciousness these have a broad range of capabilities they can sense incoming stimuli direct attention to what is important interpret environmental cues learn new information and store it in memory retrieve information produce appropriate action and even pursue goals even complex culturally derived actions like driving a car can be largely consigned to automatic processes once they are learned unconscious brain mechanisms do most of the brains work and provide the raw material that informs conscious decisions but deliberative thought can override and redirect automatic processes the two brain systems are therefore deeply intertwined and mutually dependent little of the brains action including the formation of intentions can be understood without reference to both 2 the brain automatically creates mental representations of the world and ones relation to itone of the major functions of the unconscious brain is to develop mental representations of the body and its interactions with the environment this is done on an ongoing basis largely through automatic processes that represent sensory inputs in the brain integrate them to produce complete images and associate the images with meanings these processes produce patterns of connectivity among neural structures that store 5 knowledge about the self and those aspects of the world that are relevant for 1 for instance the fishbein and ajzen model served as the conceptual cornerstone of a multicountry study of low european fertility and a conference and subsequent volume on fertility intentions see morgan sobotka andtesta 2011 2 fishbein andajzen review the development and application of their model in a range of substantive areas 3 fishbein and ajzen allow that after intentions have been repeatedly invoked to produce behavior they can be activated outside of consciousness hence some habitual actions are not immediately preceded by conscious intention formation our critique focuses on the theorys claim that conscious intentions must be formed at some point prior to the performance of a behavior 4 also referred to commonly as system 1 and system 2 liebermans c and x systems 5 store is something of a misnomer what is actually stored is the means to recreate the knowledge or image on an asneeded basis survival and wellbeing we use the term schema to refer to the elements of meaning that comprise this body of knowledge 6 7 in cognitive science a schema is defined as a relatively stable and abstract representation of the meaning of an object or event schemas can represent concepts or actions appropriate to particular contexts schemas are linked in neural networks in patterns of interconnectivity that reflect their interdependencies in our experience thus for example traditionally the schema for childrens daycare was more closely connected to motherhood than it is to fatherhood once established in neural networks cues from the environment or our own deliberative thought can trigger the activation of schemas possibly but not necessarily at a conscious level at one extreme successful reiteration of a schema can legitimate and strengthen it making it appear nonideological and noncontroversial such ncontested schemas hegemonic ones are experienced as normal and transparent modes of being or actingnot as options but as just the ways things are 3 schemas are imbued with sensation and feeling and may be linked strongly to a persons identity or sense of selfschemas do not simply represent cold facts or definitions research on embodied cognition has shown that schemas are grounded in representations of the sensory somatic and affective states registered by the brain as we learn and reproduce them the schema for baby then might engage an abstract notion of a recently born organism as well as the sound and image of the word baby but it will surely engage visual images of a round face and tiny toes the feel of soft skin and perhaps also that distinctive baby smell it will also engage feelings we have had in encountering babies did we melt with pleasure or fear dropping them these feelings and sensations experienced over time in our encounters with babies help to position the schema in relation to the neural networks in the brain that represent the self one is more likely to hold an image of the self as a future mother if ones schema for baby is positive warm and cuddly than if it suggests images of possible failure the self can be thought of as a set of schemas that characterize what and who we are in relation to the world these neural structures are deeply embodied being linked to and grounded in basic somatic sensations of continuity individuality and ownership of our own experience and actions images that are closely linked to the sense of self in turn have motivational force figure 1 summarizes the key features of our simplified model of cognition automatic processes in the brain create representations of the individuals experience of the environment these representations form a network of schemas each of which captures the semantic meaning of a common object action or concept the feelings or affect associated with it and its salience to the self through this mapping process the brain prepares itself to interpret the meaning affective value and personal significance of incoming environmental cues deliberative processes such as impulse regulation and reasoning complement and interact with the automatic processes deliberative processes draw from the information about meaning affect and selfrelevance that is provided through automatic cognition but can also reshape cognitive mappings for example a first time mother may have genuine and legitimate fears about childbirth but when they arise she substitutes new knowledge that she has learned about childbirth from a childbirth class for instance after repeated substitutions the initial fear reaction is unconsciously supplanted by a schema reflecting the normalcy of childbearing and its safety insights from social theory of course cognitive function does not operate in a vacuum where do all these schemas come from and how are they connected with affect and motivation while some basic schemas are innate most are learned through interactions with our environments and because we are first and foremost social animals our environments are predominantly social and socially structured how can social theory add to our model of cognitive function social structures are durable forms of organization patterns of behavior or systems of social relations structures are dual in nature as the lefthand box in figure 2 illustrates social structures emerge from the interplay of observable material structures on the one hand and the schematic meanings that material forms instantiate on the other for example one aspect of the motherhood structure depends both on the idea that being a parent conveys status and love and also on the presence of material objects or actions that instantiate the idea another aspect may depend mutually on ideas about investment in children and the marketing of early learning toys and programs schematic and material structures are deeply interdependent in their construction and reconstruction of social life but neither one is totally dependent on the other and each can change independently of the other social structures impact cognition in two important ways the first we discussed in the previous section over time neural networks are structured by recurrent similarly patterned experience such regularities of experience are produced by structures through interaction with the people things and events that provide material evidence of the structures that shape our social lives schemas representing the ideas scripts and values associated with particular structures take form in our neural networks path a in figure 2 illustrates this influence for example we learn that the birth of a baby is cause for celebration by observing others as they celebrate a babys birth as well as from public displays of cards and gifts for new babies learning the meanings and affective values associated with childbirth prepares us to interpret new information about a birth appropriately and to reproduce expected behavior with greater or less fidelity our responses and behaviors become part of the social environment thereby reinforcing andor modifying the material instantiation of childbirth schemas in the world second particular structures become important for action and decisionmaking when they are relevant to a specific context or situation 8 structures organize the material features of a situation the patterns of opportunity and constraint that shape action in a particular context they also influence how individuals construe a particular situation by structuring the material circumstances of particular situations structures influence the cues that evoke particular schemas in the participants brain thus structures shape what mcnicoll calls the decision environment the frames of reference or schemas through which the individual attaches meaning to a situation identifies potential courses of action and chooses among them for example consider two women experiencing an unwanted pregnancy at a university one belongs to a highly religious family and is attending a catholic university and the other from a nonreligious family is attending a private secular university although the situations faced by the two women are similar in some respects they differ markedly in others the first woman will not likely receive help from her family or student health services in obtaining an abortion and could face material sanctions if she persisted in ending the pregnancy in addition her family may provide material and emotional support for having the baby on the other hand if the second woman considered abortion she might well receive financial help and emotional support from family and easily access services through the student health services she might also face sanctions from her family and school if she carried the baby to term these women are embedded in different structures and the structures imply very distinct sets of material resources and constraints these settings also provide very different sets of cues for construal thus different structures transform a similar event into very different situations peoples experience with social structures can vary greatly an individuals experience of structures depends on his or her location within society and encountering different structures can produce differences across persons in both mental maps and in the situational cues they experience specifically individuals are located within society along socially meaningful dimensions such as age sex income and education many structures are differentially distributed across this multidimensional social space twobiologicalparent 8 we define situation as a temporary arrangements of circumstances experienced by an individual in other work we have used the term conjuncture to refer to shortterm specific configurations of structures in which action can occur to make our language more accessible to demographers we use the term situation to refer to the confluence of both material and schematic structures in a particular set of circumstances intact families are more common among the collegeeducated welfare systems mainly impact poor populations thus exposure to and identification with specific structures and the material and schematic components of which they are made depends on a persons position ascribed achieved or chosen within social space as well as his or her position in geographic space intentions a cognitivesocial model what do these ideas from cognitive science and social theory suggest about intentions we offer the following propositions that build on but expand and modify the classical psychological model figure 3 codifies our model of intentions first returning to our definition intentions entail a desire for an outcome and a belief that a certain action will bring it about thus we suggest that a woman forming an intention to become a mother would usually have a schema of parenthood associated with positive affect 9 she would also have a mental script for becoming a mother a set of schemas that linked particular actions to conceiving and bearing a child having a desire for the outcome implies that the relevant schemas are not only positively valued but linked to the self in some way perhaps as part of an image of a potential future self this linkage does not necessarily imply intention however because it may occur automatically without conscious deliberation intention formation requires not only conscious deliberation but also some degree of commitment to act we suggest that an intention is formed when the deliberative brain consciously ties both a schema for an outcome and the schemas for achieving the outcome to the self thereby motivating action 10 for example the conscious commitment to become a parent automatically establishes a firmer connection among schemas related to parenthood the action schemas necessary to achieve it and the self further the attachment of the parenthood and action schemas to the self intensifies their affective content because action is produced by emotional cues this strengthens their power to motivate action the bidirectional path c at the center of figure 3 thus shows deliberative systems of the brain both drawing on the schemas affect and selfrepresentations created through automatic processes and strengthening associations among these elements in the short term the brain stores the intention in a temporary holding area but these representations will fade over time with enough reinforcement however the intention will be integrated in the neural networks that manage longterm memory in this way conscious goals can become learned and implemented by automatic systems second as represented by path d in figure 3 our model suggests that action relevant to an outcome need not depend on the individual forming a prior intention there are two reasons for this cognitive science has shown that while we generally become aware of our actions action may precede not only conscious deliberation but also awareness provides a discussion of the neural processes involved in motivation libet et al 1983 if the schemas described above link certain actions to motherhood and if they are positively integrated in the self then they can produce action when triggered by environmental cues even in the absence of conscious deliberation for example a woman who holds very positive images of motherhood may not ever think about the possibility of abortion when faced with an unintended pregnancy 11 the other reason that relevant intentions need not precede action is that actions may be relevant to multiple outcomes so that intentional action directed at one outcome will have consequences for others if i form an intention to take action a 1 to obtain outcome o 1 and if a 1 also produces outcome o 2 then o 2 will be an unintended consequence of my action further if o 1 affects the probabilities of yet other outcomes these too may occur in the absence of any intention having sexual intercourse with an attractive partner may be driven by schemas of and intentions related to relationship formation nevertheless sexual intercourse satisfies a precondition for pregnancy and parenthood third if an intention is formed it is likely to influence not only action directed at the specific outcome it targets but also the organization and affective content of schemas directly and indirectly related to the intention because our neural networks link schemas together the changes to the schema associated with a particular action or outcome may have ripple effects that modify related schemas for instance the intentdecision to accept a demanding job may strengthen schemas that encourage and justify fertility postponement alternatively the intentdecision to become a parent could weaken a persons attachment to a particular job or to the labor force fourth intentions are framed by structure this proposition follows from the fact that the schemas we learn and use most reliably are those that we learn from observing recurring patterns of social life the very essence of structure because we are exposed to these schemas repeatedly and learn them so thoroughly they become the takenforgranted baseline assumptions for intention formation this does not mean that intentions will always mirror the dominant structural patterns but it does mean that intentions are formed in relation to a structured world for instance most persons would acknowledge the norm that one should become a parent and that one should have a second child to provide a sibling for the first born of course not all persons have exactly two children but rationales for other family sizes are frequently couched as reasonable exceptions to this widely accepted schema structure also frames intention formation by shaping the circumstances that prompt it the material cues present in structured situations elicit schemas that will produce intentions appropriate to the situation fifth we form intentions only when the circumstances of a situation demand or motivate it the formation of intentions requires the action of deliberative processes and these processes are costly to the brain they engage only when necessary generally when automatic processes are not producing a coherent story or direction for 11 miller has found evidence that fertility desires can bypass intentionality and act directly on behavior to influence fertility outcomes action this is especially likely when people confront new or unexpected situations or choices requiring tradeoffs between similarly valued options incoherence generates confusion or a sense of conflict which in turn requires deliberation and a conscious decision on how to act this view of intention formation is similar to that suggested by ní bhrolcháin and beaujouan who draw on psychology and behavioral economics in their analysis of fertility intentions they suggest that fertility preferences are constructed rather than retrieved especially in the context of unfamiliar circumstances or those that require tradeoffs an unplanned pregnancy is an example of a situation that will usually trigger the formation of fertility intentions the schemas evoked by this event are likely to be in conflict even among women who welcome it an unexpected pregnancy will throw existing representations of the future life course into conflict with schemas representing the impact of a new baby the brain will invoke deliberative processes to resolve the confusion and intentions will be formed sometimes with ease and sometimes only after extended and painful deliberation our claim that the formation of intentions depends on motivating situations also extends to women who form fertility intentions well in advance of pregnancy a marriage learning that ones current partner has decided to be voluntarily childless or committing oneself to a challenging career these situations bring parenthood structures into awareness in ways that may evoke the formation of intentions without such motivating situations there is no reason to invest in intention formation our model is highly compatible with the tra model in most respects both models account for the influence of social structure and experience on cognitive processes and behavior the beliefs attitudes and norms featured by tra can be conceptualized as schemas in our model the main conflict between the two is in whether conscious intention formation must precede behavior tra assumes it must whereas we posit that behavior can occur in the absence of a relevant intention in tra the causal path between intention and behavior is modified by variables that reflect an individuals control their ability to bring actions into line with intentions because our model is grounded in cognitive science on how the brain produces action these modifiers are unnecessary the individual and situational constraints and enablers that influence control in tra are incorporated into the production of behavior via the cognitive processes at the core of our model finally our model also goes further in key ways we make explicit the dual nature of structures in the environment and their relation to cognition via multiple pathways we also tie our model directly to knowledge about dual processes in cognition using our model to reconcile what we know about fertility intentions how does revisiting the intentions concept in the light of cognitive science and macro social theory help reconcile the seemingly contradictory facts we introduced at the outset these facts suggest three questions • why is there so much slippage between intentions and fertility outcomes • why do fertility intentions predict fertility as well as they do • what is the predictive value of intentions for fertility at the aggregate level before we address these questions however we must clarify a fundamental issue regarding the measurement of fertility intentions implications for measures of fertility intentions demographic research necessarily relies on survey reports of fertility intentions these have an ambiguous relationship to intentions as defined by psychologists and as discussed above our discussion above implies that at any given point in time an individual may or may not have formed an intention regarding a particular outcome and that in fact people do form intentions only when motivated in to do so this argument suggests that fertility intentionmaking may be a stage in a longer developmental process we envision several stages in the first stage one learns about parenthood from ones own experience of being parented and watching family life unfold in other families and through media portrayals this builds a network of schemas in the brain about what families look like how they function what parents do what makes a good parent whether parentchild relationships are loving or conflicted and so forth the second stage overlapping the first is the organization of this knowledge in relation to mental models of the self and the selftobe 12 the third stage is the conscious development of intentions we suspect that the first stage begins in childhood the second in adolescence and the third in response to specific situations in the transition to or during adulthood this conceptualization has implications for our interpretations of data on fertility intentions or expectations collected in demographic surveys given the ubiquitous nature of families and the implications of fertility for adult roles and responsibilities it is likely that most people do form fertility intentions at some point in their reproductive lives however they have not necessarily done so at the ages at which demographers begin asking them our questions demographers questions about fertility intentions almost always produce quantitative answers in western cultures the survey context demands answers and respondents will provide them in some cases the answers may reflect intentions in other cases scripts or cultural models imbued with positive affect and integrated into selfschemas in yet others answers may simply reflect basic prototypes of a family a mother father and two children for exampleperhaps associated with positive affect but not deeply integrated into a schema of a future self in the discussion that follows we refer to the measures used by demographers as reported intentions to distinguish them from the more specific psychological construct why is there so much slippage between reported intentions and fertility outcomes one of the challenges of studying fertility through an intentions framework is that so many births occur without a prior intention some of these apparently 12 warren millers work provides a similar account albeit framed in more traditional psychological terms miller emphasizes the distinction between desires and intentions noting that desires are more closely tied than intentions to genetic foundations for fertility motivation and that fertility motivation is a product of both personality traits and developmental experiences result from intentional action not using a condom to demonstrate trust for the partner or rejecting abortion on moral grounds but these intentions are often grounded in schemas that are far afield from those that would give rise to what demographers think of as fertility intentions a consideration of the proximate determinants of fertility provides a starting point for exploring these competing values and their effects on fertility outcomes much theorizing and empirical work treats fertility as the unitary outcome of interest it is the dependent variable a primary independent variable is the fertility intention this produces the simple model below of course other variables z can have direct or indirect effects as shown in but fertility results from a process that we represent using the heuristic from davis and blake where variables proximate to fertility are i sexual intercourse ii conception and iii carrying a pregnancy to term thus models and become multidimensional in the case of model fertility is strongly influenced by actions intentional or not relating to having sex using contraception and carrying the birth to term where intentions relative to these actions exist they may not accord directly with fertility intentions why our model suggests that patterns of association in neural networks are shaped by the external structures that frame social behavior and experience we speculate that the schemas that underlie fertility intentions draw on structures related to parenthood and family whereas those that inform intentions about sex contraception and abortion may be more closely associated with structures related to relationships pregnancy morality and risk many observers have blamed our high rates of unintended pregnancy on the longstanding reluctance in our culture to discuss sexuality pregnancy and contraception while saturating the media with sex we treat it as something apart from parenthood in terms used by mcnicoll schemas about parenthood and family on the one hand and sex and contraception on the other belong to separate domains of consistency if these schemas arent linked in our experiences they will not be closely linked in our mental maps and wont necessarily influence each other unless both domains are explicitly evoked by a situation there is also a second layer of multidimensionality if we acknowledge that a persons life course encompasses a range of domains for simplicity lets identify four fertility education and work leisure and relationships if we replace fertility in model c above with these variables and include in the diagram the intentions relating to each of them the complexity of the model grows exponentially as suggested previously this means that schemas intentions and actions related to work relationships and leisure can influence fertility outcomes just as those related to fertility can affect outcomes in other domains the multiplicity of structures relevant to fertility implies that individuals encounter a great many situations in which action relevant to fertility must be taken in many of these the structures and schemas that underpin fertility intentions will not play a major role further conflicts and complementarities among particular structures are likely to be accounted for when individuals form fertility intentions as a result of situations that are defined by those structures making their conflicts and complementarities evident they are less likely to be reflected in fertility intentions reported by individuals who have not yet formed intentions or whose intentions were framed in situations not evoking the conflicting structures beyond the issues raised by competing values and goals our model suggests other reasons that weaken the link between reported fertility intentions and achieved fertility what reported intentions represent may change over time before actual intentions have been formed reported intentions likely reflect schemas of parenthood the common observation in low fertility settings that behavior falls short of intentions may well reflect the move from general dispositions to more concrete plans that require tradeoffs and costs as iacovou and tavares show the realities of lived experience both in the formation and dissolution of partnerships and in the raising of children account for most modifications of individual fertility intentions once formed intentions can change in many ways they can become less salient they can change qualitatively or quantitatively increasing or decreasing the intended number of children the opportunity for intentions to change depends on how proximate they are to action when action is delayed intentions can be easily diverted or superseded by other intentions drawing on other structures why do reported fertility intentions predict fertility as well as they do although inconsistency between intentions and actual fertility is commonplace at the individual level intentions are strong predictors of fertility when compared to other variables the consensus is wellcaptured by schoen et al of all the variables examined nly marital status has an effect with a magnitude that is comparable with that of fertility intentions moreover intentions bring additional explanatory power and do not simply mediate the effects of more distal variables there are many reasons why reported intentions predict as well as they do at a cognitive level the schemas that inform the reporting of intentions in response to survey questions can influence action even when fertility intentions havent been formed positive images of family life or of the self as a future parent can spill over to influence the value attached to schemas of action that are linked to parenthood schemas in the brain such as getting married or continuing a pregnancy further the schemas that inform survey reports of intended fertility will likely overlap substantially with the schemas that inform actual intention formation making it likely that peoples responses to questions about fertility intentions will predict the intentions they later form once formed fertility intentions can affect sexual contraceptive and abortion behaviors in two ways deliberative proceptive efforts to conceive or contraceptive action but also more gradually by affecting the organization of neural networks so that the schemas associated with fertility behaviors are more closely tied to identity and more in alignment with the intentions these changes make it more likely that persons will act on an intention from a macro perspective the schemas underpinning reported intentions are learned through immersion in a particular social location characterized by particular material structures navigation of the environment gives rise to situations that elicit these schemas reinforce them and produce action that affects fertility outcomes the tendency for people to remain embedded in particular structures over time enhances the continuity and reinforcement of these basic schemas and therefore the correspondence between reported intentions informed by them and later intention formation and behavior for example the only daughter of a professional couple is likely to hold schemas of adult work and family roles that reflect her upbringing and experience these are likely to prompt a modest report of intended family size regardless of whether she has formed fertility intentions barring a youthful rebellion the same set of schemas will guide her actions in attending college and beginning a career making it likely that her completed family size will be similarly modest social structures also support the development of realistic intentions as we suggested intentions are formed in the context of situations that bring structures into ambiguous or conflicting relations to each other why is it as the evidence suggests that married women do hit their targets whereas unmarried women are more likely fall short of their intentions one reason is that being married places one in a structural position that brings parenthood to mind and increases the likelihood of situations supportive of or conducive to parenthood also marriage increases the relevance of familyrelated schemas to the self by doing so it may trigger situations that bring conflicts between selfschemas related to work and parenthood into awareness or situations that reveal an opportunity offered by the coincidence of structures marriage also entails balancing the needs of both partners as well as potentially having children putting existing selfschemas in doubt these circumstances produce intentions that have been focused through the lens of intersecting structures that constrain and facilitate the married couples life what is the predictive value of intentions for fertility at the aggregate level one of the early uses of reported fertility intentions was to predict the completed fertility for cohorts still in the childbearing years it was understood that individual women might miss this reported intention low or high but it was hoped that individuallevel errors would offset each other making the mean prediction close to the target because such offsetting does in fact occur reported intentions are necessarily better predictors of actual fertility behavior at the aggregate level than at the individual level however even aggregate reported intentions are imperfect at predicting aggregate behavio in the us recent cohorts completing childbearing have come close to meeting their expectations 13 but a common finding in other developed countries is that fertility is well below levels suggested by reported intentions how can the framework we developed above help us to understand the relationship between fertility intentions and behaviors at the aggregate level asking the question at the aggregate level focuses attention on social structure are there regularities at this level and can we identify the mechanisms that produce them in looking for macrolevel explanations that explain aggregate differences we are not denying microlevel decision making we view macrolevel dynamics as a product of the interaction of microand macrolevel processes however we assume that the major influences on aggregate measures of fertility also operate at least in part at the aggregate level and therefore are structural in our sense of the word thus emphasis moves away from what happens in the brain to the structures in the world structures shape both reported intentions and actual fertility but not necessarily in the same ways as we discussed previously intentions are framed by structure and emerge from a developmental process when people form fertility intentions they draw on schemas learned and imbued with value through their experience with structures during childhood as adulthood progresses and life course choices are made intentions will be influenced by the contemporaneous structures that enter into these decisions but this influence need not be powerful 14 intentions refer to future behavior and the further off that future seems the greater the likelihood that contemporaneous structures that conflict or compete with longstanding schemas of parenthood will be discounted at the aggregate level a shared cultural model of a best sized family emerges shaped in part by the structural characteristics of a contemporary time and place but also deeply rooted in structures of the past actual fertility is also motivated by the structures of the past but because the timing of childbearing can be manipulated it is more sensitive to current structural conditions an existing but underappreciated framework proposed by bongaarts is quite useful in pointing to the structures that can drive aggregate fertility levels up or down here we develop the model as a cohort model focused on the net difference between reported intentions and behavior over the subsequent life course 15 the model posits that aggregate behavior conclude that reproductive intentions are tailored to conditions at the time of interview and thus share the same possibilities of misinterpretation as other period indices we agree that such tailoring occurs but emphasize in addition the powerful effect of past structures in shaping the schemas that underpin intentions 15 the bongaarts model is focused on period data because it is by far the most commonly used and most widely available measure of fertility the logic of the bongaarts model follows a womans or a cohorts experience thus bongaarts proposes a synthetic cohort approach the lefthand side of the equation is the tfr often described as a synthetic cohort the fertility of women if they experienced the agespecific rates that exist in a particular year the righthand side variables include a period measure of intentions what women in a particular year say is their preferred or ideal size family the macro constraints are the ones that exist in a particular period and would thus operate on the synthetic cohort one parameter and an important one is removed as we move from a period to cohort representation this is temporal distortion children ever born ceb will mirror the cohorts earlier aggregate reported intentionsabsent unanticipated influences however unanticipated factors will cause some womens fertility to fall short of intentions while others will cause intentions to be surpassed components of s include fertility shortfalls due to subor infecundity and to competition with other goalspreferences p includes unanticipated circumstances such as an infant death an unsatisfying gender composition of ones children or an unwanted birth each leads to more births than stated intentions imply the impact of contemporaneous structures on actual fertility is most clearly evident in the components of s that reflect competing goals and preferences some women or couples may choose to postpone or forego births because they are engaged in a career or leisure activities that would be compromised by having more children births that are postponed may eventually be foregone creating smaller family sizes than intended the likelihood of competition depends upon a social environment where alternatives are available and acceptable or even encouraged synergies between family and other activities that could contribute to having more births than intended also depend on the structural environment for example an expansion of day care facilities or policies encouraging their use through subsidies could advance the timing number of births at the aggregate level shifts in the structures that define these conflicts and complementarities can have an important influence on cohort fertility rates 16 other aspects of structure also influence the relationship between intentions and births through their effects on conceptions and fertility outcomes for example some groups may have more unwanted births than others because of the difficulty of obtaining an abortion or because it is less acceptable health care religious and governmental structures can also influence the level of unwanted births by restricting access to contraception or questioning its moral value high levels of child mortality themselves a function of health care structures as well as structures that shape poverty and disadvantage may press actual fertility above intended levels insurance structures that fail to provide adequate coverage for infertility services or ensure generous coverage for contraception set the stage for a shortfall of births relative to intentions structures can also influence the relationship between intentions and actual fertility by framing peoples responses to fertility outcomes gender structures in many areas of the 16 period rates are affected directly and immediately by such postponement world shape the meanings of sons and daughters and the expected roles of boys and girls and hence give rise to preferences for the sex composition of children in the us there is a welldocumented stated preference for a mixed gender composition to have one son and one daughter common behavioral patterns instantiate this schema couples expecting a second child often openly wish for a child of the opposite sex and couples with two children of the same sex are more likely to have a third child in situations where the sex of children cannot be controlled this preference leads to higher fertility in societies where gender structures are less sharply differentiated or less salient or where such differentiation declines this effect is diminished cohort fertility depends not only on the configuration of structural influences but also on the stability of the structural environment picture the cohort of us men and women born in 1960 in the year they were born both the percent of men and women ever married and the tfr were at their highest points in the century by the time they were 20 families had changed dramatically the tfr had been cut in half declining from 37 to 18 the percent ever married had declined from 77 to 70 and the percent divorced had more than doubled other things had changed as well the proportion of us women ages 16 and older who were in the labor force had increased from 38 to 52 manufacturing was on the decline and service industries were expanding and educational attainment had increased dramatically when asked by nlsy interviewers about their intended fertility in 1982 men and women in this cohort reported an average of about 25 births this cohorts earliest family experiences occurred in the context of family structures that emphasized marriage and childbearing but the cohort came to maturity as the children of the baby boom were flooding the labor market the intentions expressed by this cohort represented a compromise between the family structures they had experienced and the structures that they now perceived as relevant to childbearing this cohort never achieved its reported target its completed fertility averaged around 2 births a further compromise as work family and other structures continued to evolve shaping not only what was possible but what was appropriate to the times the bongaarts framework focuses on the difference between reported intentions and fertility behavior in doing so it focuses on the causes of fertility behaviors and takes intentions as a given however as the above example suggests concordance between intentions and actual fertility depends on the nature and stability of structural influences on both if these influences are similar the differences between measures of intentions and fertility should be relatively small if intentions and fertility respond to different structural influences or are differentially influenced by past and present structures as we argue above then there is more room for divergence the dominant pattern in the developed world is for reported intentions to approximate replacement levels but for completed fertility to be modestly lower 17 the apparent structural story behind this gap is the tension between a relatively enduring 17 period fertility is frequently well below reported intentions a substantial part of this difference can be explained by fertility postponement culturally shared schema of the family as including at least two children rooted in dominant family structures and the tendency for antinatalist pressures to exceed pronatalist effects in contemporary economic consumption and healthrelated structures a key question is what makes the schema of the twochild family so resilient in the face of changing economic conditions is this resilience temporary a sentimental holdover from earlier times or is it driven by something fundamental in human experience evidence that intentions for one child are becoming more prevalent in parts of europe suggests that the twochild norm could be a temporary phenomenon subject to change in new generations however the us experience clearly reflects some resistance to change 18 as the discussion in this section makes clear both expressed intentions and actual fertility depend on two aspects of structures the opportunities and constraints that have long been a focus of demographers and the schematic meanings they convey it is not just the availability of jobs for women but the shared schemas about womens roles not just the access to or cost of abortion but the religious structures that color its acceptability health care structures that offer assisted reproductive technologies shape schemas about the boundaries of the fertile years and perhaps most importantly family structures leave a profound imprint on peoples ideas about the size of a proper family expanding our view of structural influences to include those that shape the meaning and value of parenthood complements analyses of structural opportunities and constraints both contribute to understanding the relationship between reported intentions and fertility behaviors bongaartss conceptualization of aggregate fertility behavior as a function of both intentions and fertilityconstraining or boosting factors provides a helpful frame for considering structural influences on fertilityintentions concordance concordanceaddressed here at the cohort level depends on the match between the structural effects on intentions and the structural conditions in which action related to fertility is undertaken perfect concordance between intentions and fertility at the aggregate level would be achieved only if the net effects of the structural conditions influencing aggregate reported intentions were equal to the net effects of the structural conditions affecting fertility even in a perfectly stable society this is unlikely the structures that give rise to intentions are not necessarily the same structures that affect fertility and even when they overlap they may have differential effects on intentions and fertility however structural conditions in a society may evolve in ways that reduce the discordance between these sets of structures just as the development of child care services has reduced the discordance between valued images of twochild families and the demands of female employment conclusions our paper began with contrasting pairs of statements on the predictive validity of reproductive intentions we reconcile these statements by presenting a socialcognitive model of intentions and exploring its implications for what fertility intentions reported in surveys may represent for individuals at different stages of their reproductive life the 18 for example between 1982 and 2002 the fertility expectations expressed by women 2024 years of age varied between 232 and 246 a range of only 14 births model links a pair of dualities at cognitive and social levels at the individual level automatic and deliberative processes in the brain interact to produce schemas intentions and action and at the aggregate level material and schematic elements of structure interact to create the social environments that shape both the schemas about families and pregnancy that people learn and the situations in which these schemas are brought to bear on intention formation and action the model identifies what cognitive and social processes give rise to intentions and how these processes as well as intentions themselves exert an influence on fertility our explanation of why fertility fails to match reported intentions at the individual level confirms common understandings but tells a richer more elaborated story there are many unintended pregnancies because there are many situations within which the dominant schemas and materials are not about fertility pregnancy is the unanticipated consequence of actions aimed at other goals thus unintended pregnancies occur because goals are many and they are frequently not tightly integrated in our cognitive processes or in the material world our explanation for the predictive validity of fertility intentions relies in part on individuallevel psychology but also on relatively neglected structural explanations that promote stability in intentions over time many of the schemas that inform womens reports of intentions are enduring the image of a family the affective value of family life and are likely to have enduring effects on later fertility even when women are surveyed before forming intentions these schemas are embedded in macrolevel structures that are highly visible and relatively stable also contributing to their durability at the individual level when an intention is formed its power to predict derives in part from the situation that gives rise to it a decision environment that juxtaposes the opportunities and constraints afforded by different macrolevel structures and focuses decisionmaking on realistic options in moving to understand the predictive power of intentions at the aggregate level our framework focuses attention not only on how social structures frustrate or facilitate intentions but also how the structural environment contributes to the formation of reported intentions in the first place intentions and fertility may respond differentially to the opportunities and constraints that structures define and the meanings that they instantiate because fertility intentions may be rooted in deeply valued longstanding schemas about the family whereas their implementation necessarily depends on contemporary structural conditions there is much room for aggregatelevel intentions and fertility to diverge over a cohorts reproductive years the size of these differences will depend on the organization and mix of structures relevant to fertility where structures exist to reduce conflict between family schemas and structural constraints intentions should have greater predictive power very generally what is the weak link in intentionfertility research do we need more observations or a better way of thinking about what we have already observed we stress the latter our data on intentions are useful but we need to better understand and use them the aim of this paper is to augment existing ways of thinking about intentions and the data demographers gather about them we argue that intentions data are useful not only when they are valid measures of the underlying psychological construct but also to a lesser extent when they are simply serving as indicators of the schemas and structures that shape peoples life trajectories much can be done with our traditional survey measures reported intentions remain one of the strongest predictors of childbearing at the individual level and an important indicator at the aggregate level but they are also misleading in that they mask the more complex set of mental and social phenomena that drive behavior by describing how these phenomena relate to intentions our model can lead to hypotheses that are testable using the data we have now for example demographers can theorize about the circumstances under which fertility intentions may be formed and how these circumstances affect their chances of being realized leading to differential specifications of models of the predictive value of intentions across life course stages demographers can also combine existing survey measures with measures of the structural environment to test hypotheses about how structures shape both intentions and their realization across the life course for example by expanding the search for independent insights into structural arrangements we can explore how structures set the scene for unintended fertility is it actually true that schemas that underlie fertility intentions draw on structures related to parenthood and family whereas those that inform intentions about sex contraception and abortion may be more closely associated with structures related to relationships pregnancy morality and risk our conceptualization of structure suggests that efforts should be made to capture not only the material structures that shape fertility but also the shared schemas that set the stage for parenthood moving beyond our existing data will require theory development at the intersection of cognitive science social science and social demography this paper is a contribution toward the needed theory development

we examine the use and value of fertility intentions against the backdrop of theory and research in the cognitive and social sciences first we draw on recent brain and cognition research to contextualize fertility intentions within a broader set of conscious and unconscious mechanisms that contribute to mental function next we integrate this research with social theory our conceptualizations suggest that people do not necessarily have fertility intentions they form them only when prompted by specific situations intention formation draws on the current situation and on schemas of childbearing and parenthood learned through previous experience imbued by affect and organized by selfrepresentation using this conceptualization we review apparently discordant knowledge about the value of fertility intentions in predicting fertility our analysis extends and deepens existing explanations for the weak predictive validity of fertility intentions at the individual level and provides a socialcognitive explanation for why intentions predict as well as they do when focusing on the predictive power of intentions at the aggregate level our conceptualizations lead us to focus on how social structures frustrate or facilitate intentions and how the structural environment contributes to the formation of reported intentions in the first place our analysis suggests that existing measures of fertility intentions are useful but to varying extents and in many cases despite their failure to capture what they seek to measure each pair of statements below is true for the contemporary us 1 fifty percent of pregnancies and 35 of births are unintended finer and henshaw 2006martinez et al 2006 and 2 intentions are the strongest predictor of a womans subsequent fertility behavior westoff and ryder 1977schoen et al 1999 3 among birth cohorts of women recently completing childbearing women missed their stated intentions at age 22 by an average of nearly one birth morgan and rackin 2010

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introduction subjective quality of life or subjective wellbeing are emerging as important measures of individual and societal progress as also envisaged by the 2030 agenda for sustainable development among the many individual factors associated with swb the quality of the neighbourhood is recently receiving growing attention as a factor shaping selfreported life satisfaction in contemporary societies the quality of the neighbourhood is considered by the united nations sustainable development goal n 3 which is aimed at ensuring healthy lives and promote wellbeing for all at all ages and goal n 11 which advocates more efforts to make cities and human settlements inclusive safe resilient and sustainable indeed the place where people live may have a strong impact on their life patterns thus from a policymaking perspective it is necessary and relevant to make neighbourhoods more inclusive to ensure the wellbeing of people neighbourhoods should provide resilient human settlements which drive sustainable development stimulate innovation and foster gender equality community cohesion and personal safety among different population groups including immigrants and their descendants according to the basic integration model which can be defined as the process of becoming an accepted part of the society immigrants and their descendants look for the same qualities in a neighbourhood as do members of the mainstream population furthermore this model recognizes that newly arriving immigrants may initially benefit from living in ethnoreligious enclaves because they offer employment and provide the comfort of being among their country of origins religious and cultural settings yet across the integration path enclave residency switches from initially beneficial to becoming increasingly disadvantageous in terms of occupation and revenue in this perspective migrants seek to live in a neighbourhood that is up to their attained socioeconomic status thus the general neighbourhood characteristics can increase life satisfaction among immigrants and their descendants previous research has showed that it is difficult to assess the quality of the neighbourhood only using objective or subjective measures most often a mix of objective measures is used together with subjective perceptions however in the realworld data collection is often limited to either subjective or objective indicators of wellbeing limiting the possibility of using the abovementioned mix of indicators based on a definition of connerly and marans for the perceived quality of the neighbourhood we intend the subjective evaluation of the characteristics and services available in the immediate neighbourhood where people live including the assessment of the local community and the frequency of social contacts outside the household but in the neighbourhood however to the best of our knowledge studies focusing on the perceived quality of the neighbourhood are still scant and mainly developed in the us indeed most of the studies on the neighbourhood focus on objective neighbourhood characteristics such as the economic wealth the residential density the socioeconomic status the ethnic composition the degree of segregation affluence or deprivation of the neighbourhood etc a large majority of these studies examine the relationship of these indicators with other objective outcomes such as education labour market participation occupational status income welfare support health residential mobility or attractiveness attitudes towards immigrants while only a few of them examine the relationship of these indicators with swb therefore in this paper we aim to fill this gap in the swb literature comparing selfreported life satisfaction of different population groups living in european countries and to analyse the association between selfreported life satisfaction and the perceived quality of the neighbourhood controlling for sociodemographic and human capital variables data stem from the crosssectional european quality of life survey of 2016 covering 28 european union countries and five eu candidate countries albania fyr macedonia montenegro serbia and turkey the choice of using subjective indicators of quality of life and of the neighbourhood is justified by the following line of reasoning as stressed by veenhoven subjective indicators are indispensable in social policy both for assessing policy success and for selecting policy goals objective indicators alone do not provide sufficient information especially not on the subject of wellbeing as a consequence the importance of objective indicators has gradually left room to subjective measures of wellbeing swb measures are typically linked to a subjective evaluation which comes by the individuals psychological and emotional sphere and can be affected by their personal attitudes therefore there is need of data collection methods that ensure unbiased and accurate estimates however the main advantages of swb measures also for assessing the quality of the neighbourhood are that they allow individuals to evaluate their own situation according to their personal criteria subjective indicators of wellbeing capture perceptions and evaluations expressed by people themselves as such they could be more appropriate than objective measures of outcomes to study individuals wellbeing furthermore individuals with similar levels of wellbeing as assessed by objective measures may report different outcomes in terms of subjective indicators of wellbeing economic cultural and institutional factors may affect these different outcomes therefore indicators of subjective wellbeing could be an alternative and appropriate way to study individuals wellbeing however it is well recognized that measures of subjective wellbeing may vary across individuals and they are influenced by time and space for the same individual consistently with this research strand kaiser and oswald using longitudinal data from australia germany and uk have recently shown that subjective indicators of wellbeing entered linearly in a regression performed fairly impressively when compared against a group of objective economic and social variables entered together in a regression furthermore research on neighbourhood features and life satisfaction have showed that neighbourhood satisfaction is a significant predictor of life satisfaction using subjective measures such as neighbourhood satisfaction does not come without limitation data are collected in surveys are often based on selfreports therefore they may be too noisy to offer any conclusion however according to social psychologists aggregation over a large amount of people may ensure reliability of data based on individual scores characterized by a certain amount of noise a second limitation is also linked to measurement bias respondents may have individual or group tendencies to give more positive or negative answers to subjective questions regarding both perceived quality of the neighbourhood and life satisfaction due to social desirability or other reasons there would be a spurious relationship and the results obtained could suffer of an estimation bias however few studies have so far addressed the wellbeing at fine geographical level indeed studying the association between life satisfaction and a subjective measure of the quality of the neighbourhood may offer important insights for urban planning and community policy overall there is a need to conduct more studies at the micro level based on subjective indicators the paper is structured as follows theoretical background and study hypothesis section displays the theoretical background and our research hypotheses data measures and method section presents data measures and methods followed by the results of our analysis in results section the last section reports the discussion and conclusions of our research theoretical background and study hypothesis swb and migration swb has been defined by oecd as how people feel or how they assess their lives looking at wellbeing from a subjective point of view means conceptually converging towards quality of life swb consists in three components life satisfaction happiness and eudemonic wellbeing happiness is a concept which defines peoples emotional evaluation and measures their current feelings or moods while life satisfaction is the cognitive dimension of wellbeing and it is a measure of peoples personal evaluation of their life as a whole lastly eudemonic wellbeing is a concept which focuses on judgments about the meaning and purpose of ones life previous studies suggest some caution in using the concept of happiness as it has a different meaning in different languages and cultures it is more ephemeral and it depends directly on emotions such as joy anger or distress the concept of life satisfaction in particular overall life satisfaction or one item satisfaction has the advantage to show strong reliability and less variability over time when repeatedly measured for the same person therefore in this paper we have chosen to use selfreported life satisfaction as a measure of swb in literature there are four main approaches to study swb and migration the first one looks at how swb affects migration decisions conceived as both aspirations to leave and actual migration behaviours in order to know if swb is a driver of migration the second one analyses how migration affects the swb of migrants more specifically it compares the swb of migrants to that of nonmigrants in the country of origin to assess whether swb increases after migration an emerging approach focuses on the impact of migration on the swb of the hosting populations to understand how natives perceive migrants finally the fourth approach looks at the differences in the swb of migrants and natives and the main associated factors this is one of the most difficult approaches because of the scarcity of suitable data however this approach is important to verify if immigrants are satisfied as natives and to understand the reasons that could foster or hinder the achievement of a condition of parity with natives since for immigrants the achievement of this condition could mean the realization of the integration process in the host society this kind of comparison is particularly interesting and useful for effectively implementing inclusive integration policies this is the approach that we will follow in this study life satisfaction across european countries and population groups the focus of most of the studies on immigrants swb is one national context because of the lack of surveys measuring immigrants swb in european countries few comparative studies on the swb of immigrants living in european countries have been conducted so far furthermore most of the available studies are based on the european social survey which allows for comparisons between migrants and nonmigrants and across immigrant generations all the studies realized so far in the european context have found that immigrants report lower swb compared to natives even if those studies as already stressed are mainly based on ess data they differ not only in their aim but most importantly in the choice of the control variables used safi and kirmanoğlu and başlevent relying on ess data showed that there is a gap between life satisfaction of immigrants living in europe and natives the former reporting lower levels of life satisfaction moreover this gap strongly affected by discrimination continues even when considering the immigrant generation and the length of stay using data from the 20022003 wave of the ess beier and kroneberg found that symbolic boundaries have an impact on the life satisfaction of only first and secondgeneration immigrants with limited proficiency in the majority language arpino and de valk studied immigrants and natives in 34 european countries taking also into account immigrants generation their findings show that first generation immigrants life satisfaction is lower compared to natives one while the gap is reduced for second generation immigrants and 25 generation immigrants however in their study no control for income is used contrary to the other studies mentioned in this review in the literature it is largely acknowledged that income have a positive impact on swb thus omitting this important factor may have brought different results compared to other studies the study of tegegne and glanville is based on the data from the first five waves of the ess their research suggests that reduced social capital is the main explanation to the lower level of swb of immigrants in 15 european countries compared to their nativeborn counterparts they also found a bigger gap in swb between immigrants and natives their higher levels of social capital coming from religious involvement are however not sufficient to compensate for the gap with natives heizmann and böhnke distinguishing between national citizens eu citizens and thirdcountry nationals found that only tcns benefit from inclusive integration policies in terms of life satisfaction eu immigrants are more affected by the negative impact of natives antiimmigrant attitudes using data from the 20102016 period of the ess for 17 european countries hendriks and burger showed that the development of less positive perceptions of the host countrys economic political and social conditions is associated with a reduction of firstgeneration immigrants swb although they have a swb advantage compared to natives because of their more positive societal perceptions finally using data collected by the ess from 2002 to 2018 stranges et al measured the relationship between immigrants selfreported life satisfaction and their absolute and relative income the latter compared with that of natives and other immigrants with similar characteristics in the country of residence they found a stronger association between immigrants life satisfaction and the absolute income than the relative income however life satisfaction is more strongly associated with income relative to natives than income relative to other immigrants this is especially true for more educated immigrants who are more concerned in comparisons with reference groups however it is important to note that subjective measures of the own economic condition and the national socioeconomic institutional condition moderate the relationship between relative income and swb by adopting the multilevel analysis the study of kogan et al examined the nationallevel traits from three aspects namely the climate of immigrant reception the extent of public goods provision and the level of economic inequality immigrants are likely to be more satisfied in countries that offer more welcoming social settings however this association is significant only when the social setting is measured by attitudes of the nativeborn towards immigrants rather than by legal immigration regulations and policies when considering the extent to which host country is able to provide public goods countrys wealth levels seem not to matter for immigrants life satisfaction whereas countries levels of human development is associated with an increase in immigrants life satisfaction the role of economic inequality varies with immigrants own socioeconomic statuses on average immigrants are less satisfied with their lives in host countries with higher levels of economic inequality however highly educated immigrants tend not to perceive economic inequality of the country as an obstacle of their satisfaction life satisfaction and the perceived quality of the neighbourhood in a pioneering study with data from the national opinion research centers continuous national survey in 19731974 fernandez and kulik explored the effects of individual attributes neighbourhood composition and social comparison on selfreported life satisfaction they first predicted an individuallevel model using traditional variables that predict life satisfaction then they considered neighbourhood context variables by including the percentage of neighbourhood residents who are white the neighbourhoods estimated cost of living estimated income inequality within the neighbourhood and a dummy variable if the neighbourhood is urban among the individuallevel predictors of life satisfaction they found selfreported health status age education and marital status as far as the neighbourhoodcontext variables they found that persons living in a neighbourhood with a high cost of living are less satisfied with their lives than those in lowcost neighbourhoods and persons living in cities are less satisfied than those living in rural areas connerly and marans explored the individual factors that are more likely to affect two global measures of perceived neighbourhood quality satisfaction and attachment using data collected in the university of michigans 1975 study of the quality of life in detroit they found that having nearby friends or relatives plays a significant role in both satisfaction and attachment in particular while the length of residence age and having children are significantly associated with feeling attached to ones neighbourhood their impact on satisfaction is not significant specific neighbourhood attributes assume a dominant role in predicting satisfaction finally the degree of how neighbours are like or unlike respondents is strongly associated with both attachment and satisfaction using a mail survey among residents of western virginia sirgy and cornwell tested how satisfaction with neighbourhood social physical and economic characteristics affect life satisfaction they found that satisfaction with the neighbourhoods social features contributes to community satisfaction which in turn affects life satisfaction while satisfaction with the neighbourhoods physical and economic features affects life satisfaction through the mediating role of housing and home satisfaction dittmann and goebel studied the impact of socioeconomic conditions and social integration into a local neighbourhood and life satisfaction in germany using the german socioeconomic panel study enriched with data from the micromarketingsystem and consult gmbh for the years 20002006 they showed that living in a neighbourhood with a higher socioeconomic status increases life satisfaction moreover the individual gap between a persons economic status and the status of the neighbourhood also affects life satisfaction life satisfaction decreases when the person lives in a neighbourhood with a higher socioeconomic status than his or her own thus demonstrating the existence of an absolute and relative effect of neighbourhood status on life satisfaction finally the availability of social networks has a strong positive effect on life satisfaction using data from residents of five neighbourhoods in the minneapolisst paul metropolitan area in 2011 cao studied the relationship between objective neighbourhood characteristics and life satisfaction controlling for other sociodemographic factors the author showed that high density and poor street connectivity negatively influence life satisfaction varela et al examined the effect of neighbourhood satisfaction feeling safe at home and feeling safe in the neighbourhood on life satisfaction controlling for age and gender among 808 chilean adolescents analyses showed that there is a direct effect of neighbourhood satisfaction home safety neighbourhood safety and age on life satisfaction moreover home safety and neighbourhood safety have a direct effect on neighbourhood satisfaction finally there is a positive indirect effect of feeling safe at home and feeling safe in the neighbourhood on life satisfaction finally hong and park analysed the spatial effects of social capital and urban characteristics on life satisfaction in 219 cities in south korea from the korean community health survey conducted in 2011 2013 2015 and 2017 the empirical results show that income ginicoefficient social trust social networks with friends participation in charity activities leisure activities cultural facilities and availability of parks all affect life satisfaction in a positive way except for ginicoefficient according to which an increase of income inequality harms life satisfaction research hypotheses based on the evidence described so far and the information available in the eqls we make the following hypotheses h1 firstand secondgeneration immigrants report lower life satisfaction compared to natives h2 a positive subjective evaluation of the characteristics and services available in the immediate neighbourhood where people live is positively associated with life satisfaction h3 direct contacts with friends family members or relatives outside the household but in the immediate neighbourhood that are more frequent are positively associated with selfreported life satisfaction while indirect contacts are negatively associated with it h4 country of residence matters for swb socioeconomic characteristics of the country of residence are associated with swb data measures and method data data stem from the european quality of life survey of 2016 a unique paneuropean survey the survey deals with several issues such as employment income education housing family health and worklife balance it also looks at swb topics such as happiness selfreported life satisfaction satisfaction with the present state of the economy satisfaction with the way democracy works in the respondents country of residence satisfaction with the accommodation satisfaction with the local area satisfaction with the hospital or medical specialist services selfperceived health1 etc the sample consists of the adult population selected randomly for a facetoface interview the eqls of 2016 includes 28 european union member states and five candidate countries albania fyr macedonia montenegro serbia and turkey the final sample is composed of 30205 individuals measures we have selected selfreported life satisfaction as the dependent variable selfreported life satisfaction was measured on a scale from 1 to 10 the question was all things considered how satisfied would you say you are with your life these days please tell me on a scale of 1 to 10 where 1 means very dissatisfied and 10 means very satisfied based on previous findings we selected the following independent variables sociodemographic variables gender and females age age squared marital status having children and no place of residence migration background human capital variables educational attainment occupational condition and income indicators of the perceived quality of the neighbourhood satisfaction with the accommodation a synthetic indicator of problems in the immediate neighbourhood of the respondents home such as noise pollution air quality presence of garbage in the street heavy traffic in the immediate neighbourhood measured with a dichotomic variable comparing those who reported having at least one major problem in the neighbourhood with those who did not report any major problem in the neighbourhood feeling of safety at night in the neighbourhood a synthetic indicator of availability of services in the immediate neighbourhood such as banking facilities public transport facilities cinema theatres or cultural centres recreational or green areas and grocery shops or supermarkets measured with a dichotomic variable comparing those who reported to have at least one difficulty to access services in the neighbourhood with those who did not report any difficulty to access services in the neighbourhood all people are treated equally in hospital and specialist medical services in my area frequency of direct contacts with family members or relatives living outside the household but in the immediate neighbourhood frequency of direct contacts with friends living outside the household but in the immediate neighbourhood frequency of indirect contacts with family members or relatives living outside the household but in the immediate neighbourhood and frequency of indirect contacts with friends living outside the household but in the immediate neighbourhood variables 10 11 and 15 were also interacted with migration background based on previous findings as characteristics of the country of residence we chose three variables unemployment rate gdp per capita and life expectancy at birth data were retrieved for each country in the world bank database for the year of survey method as a first step we carried out descriptive analyses in order to study the association of observed variables on swb at different levels we implemented a series of twolevel hierarchical linear regression models 2we have a total sample of 29864 individual and 33 countries results descriptive statistics our respondents show a quite high selfreported life satisfaction as shown in fig 1 129 of them score their life satisfaction at 5 while 114 have life satisfaction with a score of 6 193 of the respondents report life satisfaction at level of 7 233 of the sample feel satisfied with their life with a score of 8 107 have a selfreported life satisfaction of 9 and 99 report a 10level perceived satisfaction the remaining 95 of respondents report a life satisfaction lower than 5 looking at our sample life satisfaction by migration background we notice that the life satisfaction mean value is similar among natives g1 and g2 however looking at the per cent distribution among the scores g2 have the highest percentage of scores 7 and 8 followed by g1 natives and g2 and finally g1 has the highest percentage of score 10 followed by g2 among immigrant generations selfreported life satisfaction has a higher variance compared to natives and it is more concentrated in the scores ranging from 7 to 10 as for the independent variables our respondents average 496 years of age with a preponderance of women married with children residing in a village or a small town native of the country of residence they have high educational attainment they are predominantly employed and the average income is 13095 euros in ppp as far as the perceived quality of the neighbourhood is concerned respondents are quite satisfied with their accommodation half of them have reported at least one problem with noise pollution air quality presence of garbage in the street heavy traffic while they are neutral to the feeling of safety in the neighbourhood the respondents feel to be treated equally in hospital in their area they find that the services offered in their neighbourhood are quite good when it comes to the availability of bank facilities public transport facilities cinema theatres recreational facilities and green areas and grocery and supermarkets shops lastly the respondents have regular direct and indirect with family members and friends living in the same neighbourhood and with family members and friends living in the neighbourhood country levels variables used have respectively the following mean values for the 33 countries included in the survey unemployment rate 97 gdp per capita 28829 and life expectancy at birth 797 years regression results tables 2 and3 show the results of the hierarchical linear regression model in model 0 we first include only the intercept we then add the individual level characteristics in the models 1 to 4 in model 5 we included a full set of variables at both the country and individual level the results of models 13 are presented in table 2 together with random effects while in table 3 are presented the results of models 45 model 0 is the null model used to calculate the intra class correlation and provides information on how much variation in the outcome exists between level2 units the results of the model confirm the need to use a hierarchical strategy model 1 includes only the migration background in order to provide the baseline average in swb between natives and immigrants across european countries the results show that both firstand secondgeneration migrants have lower swb compared to natives however only the results for firstgeneration migrants are weakly statistically significative in model 2 we control for sociodemographic and human capital variables as far as the demographic variables are concerned women are more satisfied with life than men age is negatively associated with life satisfaction the higher the age the lower is the level of selfreported life satisfaction however the age squared is positive this means that the relationship between age and life satisfaction is not linear and the negative association between life satisfaction and age is reduced as individuals get older having children is positively associated with life satisfaction living in urban areas irrespectively of the dimension of the city or the town is negatively associated with selfreported life satisfaction compared to living in the countryside first and secondgeneration immigrants are less satisfied with life compared to natives compared to model 1 the gap with natives in swb is reduced and it is significant only for first generation migrants concerning the human capital factors as expected people with primary and secondary education exhibit lower levels of life satisfaction than those with tertiary education moreover those who are students and employed show the highest levels of life satisfaction finally individual with at higher income levels correspond higher levels of swb in model 3 we added the variables related to the perceived quality of the neighbourhood having at least one problem with the noise pollution air quality presence of garbage in the street and heavy traffic in the immediate neighbourhood is negatively associated with selfreported life satisfaction on the contrary feeling safe at night in the neighbourhood is positively associated with life satisfaction similarly the availability of public transport facilities cinemas theatres cultural source authors elaboration of the eqls overall hierarchical regression results show that the sociodemographic variables the human capital factors and the indicators of the perceived quality of the neighbourhood are all important in explaining selfreported life satisfaction among immigrants and natives in european countries in model 4 we add to model 3 an interaction of the variable migration background with income satisfaction with accommodation and feeling that all people are treated equally in hospital and specialist medical services in the neighbourhood the results show a negative relation by migration background compared to natives however in this model migration background shows a positive relation with swb compared to natives those findings reveal a stronger association of the living conditions thus of the socioeconomic integration with the life satisfaction of immigrants compared to natives as final model we run model 5 where we introduce 3 variables as proxy of the socioeconomic conditions at the country level the three variables are significant and go in the expected direction more specifically the higher the unemployment level in the country the lower the swb the higher the gdp per capita and the life expectancy the higher the swb discussion and conclusions the topics of swb and happiness are becoming increasingly popular among scholars researchers and policymakers they are perceived as important as gdp and other macroeconomic indicators in evaluating the wellbeing of individuals and countries in particular selfreported life satisfaction refers to how people judge their life as a whole therefore it is a rational evaluation of ones situation according to personal criteria since it contains a cognitive evaluation of peoples current needs and future expectations it is considered particularly useful to estimate the quality of life within a country or a social group recently the quality of the neighbourhood both objectively and subjectively measured is capturing growing attention as a factor shaping individuals swb as also envisaged by the 2030 agenda for sustainable development however to the best of our knowledge studies measuring the relationship between life satisfaction and the perceived quality of the neighbourhood in the european context are still very few in this paper we aimed to fill this gap in the literature analysing the association between selfreported life satisfaction and several indicators of the perceived quality of the neighbourhood controlling for other sociodemographic and human capital variables and the socioeconomic characteristics of the country of residence among immigrants and natives in europe data stem from the crosssectional european quality of life survey of 2016 in particular we tested four research hypotheses our results are mixed in the first three models firstand secondgeneration immigrants have lower level of selfreported life satisfaction compared to native however differently from most previous studies when interaction with income and quality of the neighbourhood factors are introduced we found that first and second generation immigrants report higher selfreported life satisfaction compared to natives in particular those belonging to the second generation are the most satisfied with life as also found by giovanis however this finding is mediated by other variables that are more linked to immigrants socioeconomic integration in the country of residence such as income satisfaction with the accommodation and perceived discrimination in the provision of health services such results confirm that immigrants are more disadvantaged compared to natives in terms of living conditions and access to services second our findings show that the positive subjective evaluation of the characteristics and services available in the immediate neighbourhood where people live is positively associated with selfreported life satisfaction previous research has shown that there is a positive relationship between neighbourhood characteristics and life satisfaction in particular as reported by giovanis the availability of sociocultural and recreational activities in the neighbourhood increases the life satisfaction of both natives and immigrants suggesting the importance of the quality of the neighbourhood for the sociocultural integration and in policy terms for the creation of inclusive secure and happier communities third as far as the attachment to the neighbourhood is concerned having less frequent direct facetoface contacts with friends or neighbours is positively associated with life satisfaction having less frequent contacts with any family members or relatives by phone on the internet or by post is positively associated with life satisfaction having less frequent contacts with friends or neighbours by phone on the internet or by post is negatively associated with life satisfaction therefore it seems that is less important to have indirect contact with family members while with friends the opposite is true previous research has shown the positive relationship between contacts and social networks in the neighbourhood and life satisfaction for instance the attachment to the neighbourhood is a factor increasing life satisfaction and therefore a reason for continuing to live in the same place of residence instead of moving to another neighbourhood finally the characteristics of the country of residence matter for both native and immigrants life satisfaction immigrants are more satisfied in countries with higher quality of life captured by country gdp per capita life expectancy and unemployment rate the paper has provided evidence to support the notion that the perceived quality of the neighbourhood and the interrelated factors can have positive results in terms of life satisfaction there is also evidence of immigrantsnatives differentials which are essentially due to integration gaps this highlights the need for targeted rather than broad policy interventions to maximise the positive contribution of the main factors associated with life satisfaction since the integration process takes place primarily at the local level with cities and municipalities as the places where immigrants are received find a home and a job have children and access to health facilities and natives encounter new cultures and identities we believe that improving the quality of the neighbourhood characteristics and facilitating social networks and sense of attachment is beneficial of the wellbeing of both immigrants and natives however there are some limitations to the study which must be recognized first this study is based on a crosssectional survey this means that the situation at the date of observation alone is analysed therefore the effect of specific life course events on life satisfaction can be only evaluated retrospectively moreover we cannot exclude reverse causality between the variables studied given the crosssectional structure of the data for instance we cannot establish the direction of the relationship between income and life satisfaction in other words we do not know if income increases life satisfaction or if people with a higher life satisfaction are more likely to achieve a higher income the use of longitudinal data could help to shed light on the causality between variables however although much progress has been done longitudinal data are still scant or not entirely suitable for the examination of changes in swb third information such as the causes of migration the country of origin the ethnic composition the ethnic density and the socioeconomic status of the neighbourhood are not available in the eqls therefore we could not assess the association of those variables with life satisfaction finally the neighbourhood support and a sense of community are indicators that are positively associated with life satisfaction however the eqls do not provide this information cultural constructions of selfhood as well as values norms selfcentred or distallycentred prioritization of the pursuit of wellbeing etc all vary widely across different cultures among immigrants and refugees generic solutions for generic people have little practical meaning and value beyond theoretical framings a useful next step would be to pursue a translational study investigating such cultural variables that could produce findings to inform targeted policy changes moreover exploring methods to promote multicultural awareness in schools through social media and internet platforms to educate the public and relevant stakeholders about the importance of reducing discrimination towards immigrants may be crucial we also believe that encouraging immigrants to participate in public hearings and voice their concerns and dissatisfactions to the authorities can foster inclusiveness and ensure that the perspectives of immigrants are considered in policymaking and community development data availability the data sets used in the current study are available in the uk data service european foundation for the improvement of living and working conditions european quality of life survey integrated data file 20032016 data collection 3rd edition uk data service sn 7348 doi doi org 10 5255 ukdasn73483 authors and affiliations elena ambrosetti 1 • angela paparusso 2

subjective wellbeing swb is emerging as an important measure of individual and societal progress among the many individual factors associated with swb the quality of the neighbourhood is recently receiving growing attention as a factor shaping selfreported life satisfaction in contemporary societies however to the best of our knowledge studies focusing on the perceived quality of the neighbourhood are still scant we aim to fill this gap comparing selfreported life satisfaction of different population groups ie immigrants and natives living in european countries and to analyse the association between selfreported life satisfaction and the perceived quality of the neighbourhood controlling for individual sociodemographic and human capital variables and socioeconomic characteristics of the country of residence the data are drawn from the crosssectional european quality of life survey eqls of 2016 our findings reveal that first and secondgeneration immigrants report lower selfreported life satisfaction compared to natives moreover our findings show that the positive subjective evaluation of the characteristics and services available in the immediate neighbourhood where people live is positively associated with selfreported life satisfaction there is also a positive relationship between contacts and social networks in the neighbourhood and selfreported life satisfaction finally the characteristics of the country of residence matter for both native and immigrants life satisfaction with immigrants being more satisfied in countries with higher quality of life captured by country gross domestic product gdp per capita life expectancy and unemployment rate

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introduction globally maternal health issues persist as significant concerns pregnancy and childbirth are the primary factors contributing to illness and death among women of reproductive age according to the world health organizations maternal mortality report for 2020 this issue is reiterated in the third sustainable development goal which aims to decrease the worldwide maternal mortality ratio to below 70 per 10000 and guarantee widespread availability of sexual and reproductive healthcare services including comprehensive family planning information education and the incorporation of reproductive health into national strategies and programmes by 2030 worldwide the population is growing at an accelerated rate due to advancements in medicine and illness control conversely affluent nations have experienced a decrease in population growth due to intentional strategies aimed at having fewer children accomplished via the use of birth control procedures in contrast many poor and undeveloped countries continue to have high birth rates as on the united nations mediumvariant forecast the worldwide fertility rate is projected to reach 22 live births per woman by 2050 and 19 by 2100 by 2050 the fertility rate in subsaharan africa is expected to decrease to 31 births per woman and by 2100 it is forecast to further decline to 21 births per woman in 1990 the number of women in their reproductive years who use contraception has significantly increased compared to now in 2019 globally 49 percent of women between the ages of 15 and 49 were using contraception which marks a rise from 42 percent in 1990 according to ameyaw et al in africa the nations with the lowest rates of contraceptive usage also have the greatest fertility rates as well as the highest rates of newborn child and maternal death the fertility reduction in subsaharan africa has exhibited a comparatively gradual pace and has been delayed in comparison to other geographical areas in 1950 the total fertility rate exceeded 60 live births per woman in eastern and southeastern asia northern africa and western asia oceania and subsaharan africa the total fertility rate in eastern and southeastern asia decreased from 60 to 40 live births per woman during a span of 24 years namely from 1950 to 1974 in contrast northern africa and western asia saw a similar fall in fertility although it took only 19 years from 1974 to 1993 on the other hand oceania witnessed a reduction in fertility over a longer period of 35 years from 1968 to 2003 based on the united nations projections for 2020 it is estimated that it may take 34 years for the fertility rate in subsaharan africa to decrease from 60 to 40 live births per woman specifically from 1995 to 2029 although the fertility rate in subsaharan africa was higher than other regions in 2019 several countries in this area have experienced significant declines in total fertility in recent years from 2010 to 2019 subsaharan africa had significant declines in the total fertility rate in 7 out of the top 10 countries chad ethiopia kenya malawi sierra leone somalia and uganda the utilisation of contraceptive methods had a rise in all areas from 1990 to 2019 the prevalence of contraceptive use among women of reproductive age in subsaharan africa witnessed a rise from 13 in 1990 to 29 in 2019 similarly in oceania the usage increased from 20 to 28 in western asia and northern africa from 26 to 34 in central and southern asia from 30 to 42 and in latin america and the caribbean from 40 to 58 by 1990 all regions except for northern america and europe had already achieved a contraceptive usage rate exceeding 50 percent in northern america and europe the usage rate increased from 57 percent in 1990 to 58 percent in 2019 in eastern asia and southeastern asia the rate increased from 51 to 60 percent in australia and new zealand the rate increased from 56 to 58 percent the source of this information is the united nations in the year 2020 an negative correlation exists between the utilisation of contraceptives and the level of fertility countries characterised by a significant number of women utilising contraception tend to have reduced levels of reproduction the link which was seen in both 1990 and 2019 has undergone changes throughout time in 2019 subsaharan african nations exhibited higher fertility rates compared to other areas across all levels of contraception usage contraceptive usage and fertility are also impacted by additional variables the prevalence of contraceptive techniques within a community significantly influences fertility rates as certain methods such as longacting and permanent ones exhibit higher efficacy in preventing conception compared to others aside from social and economic factors several crucial factors that influence the fertility rate in a population are the frequency of abortion the length of time after childbirth when a woman is not able to conceive due to breastfeeding and abstaining from sexual activity the occurrence of secondary infertility and the percentage of the population that is married in a relationship or sexually active anticipated expansion in the adoption of contemporary contraceptive methods is projected to result in more declines in fertility rates consequently this trend is likely to significantly decelerate population growth particularly in subsaharan africa nevertheless in order to attain the expected reductions in fertility rates it is imperative to persist in efforts towards gender parity and the empowerment of women this can be achieved by enhancing male involvement in family planning advocating for female education eradicating all manifestations of violence and prejudice against women abolishing early coerced and child marriages and guaranteeing womens equal access to employment opportunities social safeguards and political engagement in order to fulfil the goal of ensuring that everyone has access to sexual and reproductive health services information and education by 2030 it is necessary to provide more assistance for family planning this may be achieved by implementing efficient government policies and initiatives the international conference on population and development programme of action established a commitment by governments to facilitate the fulfilment of reproductive objectives for couples and individuals additionally in the 2030 agenda for sustainable development global leaders made a vow to ensure that no one is excluded or neglected in order to fulfil these obligations it is imperative to adequately address the need for family planning by allocating resources and ensuring universal availability of reproductive and healthcare services nigeria boasts the highest population in africa and ranks sixth globally with a population exceeding 200 million according to the united nations population prospect 2022 the united nations projects that nigerias population will reach around 40131 million by the year 2050 as per the united states census bureau nigerias population is projected to exceed that of the united states by 2047 reaching 37925 million this will make nigeria the third most populous country in the world according to the usaid the primary factors driving nigerias population increase include early marriages elevated birth rates and limited availability of family planning services the birth rate in nigeria stands at approximately 37 births per 1000 individuals despite the nigerian governments efforts to control population growth by providing free contraception for the past decade the population growth rate has not decreased as a result current projections estimate that nigeria will have over 390 million residents by 2050 the primary objective of family planning is to avoid unintended pregnancies effective implementation of family planning strategies can significantly decrease maternal mortality rates by reducing the frequency of pregnancies abortions and highrisk births consequently it can be inferred that nigerias elevated rates of maternal infant and child mortality may be attributed at least in part to the limited utilisation of family planning services from an economic perspective family planning assists in mitigating the financial and emotional responsibilities associated with motherhood households with a reduced number of offspring who are in good health have the ability to allocate additional resources towards ensuring their children have sufficient provisions such as nourishment clothes shelter and educational prospects the utilisation of contemporary contraceptive methods is widely recognised as a crucial intervention in attaining national and international objectives as it has demonstrated efficacy in diminishing mother and child mortality and morbidity pregnancy and delivery are the primary causes of illness and death among women of reproductive age making maternal health issues a significant worldwide concern empirical evidence has demonstrated that promoting timely prenatal care visits hospital births postnatal care and the adoption of contraceptives are crucial factors in enhancing maternal wellbeing contraceptives are a crucial element of primary health care and a fundamental aspect of ensuring safe motherhood they have a vital role in decreasing the morbidity and mortality rates of both mothers and newborns by preventing unplanned pregnancies and ensuring sufficient time between births a tightly spaced birth interval would pose a threat to the lives of the mother the newborn and the older sibling if a mother falls pregnant quickly after giving birth she has a higher likelihood of experiencing difficulties such as miscarriage excessive bleeding after childbirth and a deficiency of red blood cells additionally the newborn may experience low birth weight andor be born prematurely furthermore the index kid who has already been born may experience insufficient care and assistance resulting in increased susceptibility to diseases and malnutrition most women often resume sexual activity within a few weeks after giving birth the duration of postpartum infertility in women is widely diverse and influenced by several factors such as breastfeeding status ovulation can transpire despite the absence of the mothers menstrual cycle and may transpire as early as 25 days after childbirth the likelihood of ovulation happening prior to the return of menstruation rises as time progresses postpartum family planning aims to avoid unwanted and closely spaced births within the initial 12 months after giving birth unfulfilled requirements may result in unforeseen and accidental pregnancies hence heightening the likelihood of unfavourable health consequences for both the mother and the newborn who has advised that there should be a 24month gap between a live delivery and attempting the following pregnancy in order to minimise the likelihood of negative consequences for the mother foetus and newborn having access to and possessing information about family planning are factors that can predict the use of family planning services family planning services in nigeria are available at all levels of healthcare including basic secondary and tertiary care ensuring accessibility for the population multiple studies have indicated that there is sufficient awareness about family planning however this is mostly observed among urban inhabitants and women with at least a secondary level of education consequently the lack of sufficient awareness about family planning among the rural population which constitutes 80 of the total population increases the probability of not utilising the available services several research have aimed to examine the factors behind the poor use of contraceptives in nigeria and other african countries in their study maitanmi et al investigated the level of awareness and usage of family planning services among women in the reproductive age group at the ilishan community health clinic in ogun state nigeria the study demonstrated that women of reproductive age had a commendable understanding of family planning services however despite this favourable knowledge the utilisation of such services remains relatively inadequate the inadequate use of these services was attributed to variables such as low socioeconomic level religious beliefs and limited education ackerson and zielinskis studies uncovered a significant underutilisation of contemporary contraceptives in over ten subsaharan african nations this is mostly attributed to a lack of confidence in western medicine and inadequate awareness of family planning methods in nigeria the contraceptive prevalence rate is quite low being at 17 among presently married women aged 1549 years out of this percentage 12 rely on contemporary contraceptive methods while 5 opt for traditional methods as reported by the nigeria demographic and health survey in 2018 in their study on awareness and use of contraceptives among postpartum women in a rural community anate et al determined that all the respondents were aware of contraceptive techniques the prevalent forms of contraception include male condoms implants injectables and tablets just 125 individuals accounting for 385 of the respondents reported utilising a contemporary form of contraception the multivariate analysis revealed that expressing a desire to have further children and possessing a strong understanding of family planning were both influential factors in the use of postpartum services an exploratory questionnaire evaluated the understanding and utilisation of family planning services among 85 female individuals receiving care at a comprehensive health facility in ogun state the results indicated that the degree of information regarding family planning was higher than normal with 558 of participants demonstrating excellent knowledge however the use of family planning services was lower than usual as 558 of participants exhibited insufficient utilisation as per the findings of the ondo state primary health care researcher ifedore family planning statistics revealed that the projected target for family planning in the year was approximately 13000 however only 5473 women aged between 1549 years actually utilised family planning services the most prevalent method of contraception employed by these women was injectables the primary factors contributing to the poor adoption of family planning among women in this region are lack of knowledge and apprehension over the potential adverse effects of contraception in the ifedore local government of ondo state nigeria the researcher found that a significant number of postpartum women in the community have a short birth interval additionally it was observed that some of these women who seek family planning services at the health facility do not do so promptly consequently they unknowingly become pregnant again before visiting the health facility for family planning and this is typically detected through a pregnancy test currently family planning is ineffective as many postpartum women are unwilling to continue their pregnancies due to the stigma associated with short birth intervals consequently they choose to undergo abortions which can lead to additional complications and ultimately contribute to a high maternal mortality rate in the country it is for this purpose that the researchers aim at assessing the knowledge and utilisation of family planning services among postpartum women attending postnatal clinic in selected health centres in ifedore local government ondo state the broad objective of this study is to investigate awareness and utilisation of family planning among postpartum women attending postnatal clinic in selected health centres of ifedore local government of ondo state the specific objectives are to 1 determine sources of information about family planning at ifedore local government ondo state 2 examine common methods used by respondents for family planning at ifedore local government ondo state and 3 examine knowledge utilisation of family planning and perceived attitude of workers by respondents at ifedore local government ondo state research hypotheses h01 there is no significant effect of factors influencing utilisation of family planning by respondents h02 there is no significant relationship between awareness and utilisation of family planning methodology descriptive design was used to assess the awareness and utilisation of family planning among postpartum women attending postnatal clinic in selected health centres at ifedore local government ondo state ondo state is a state located in the southwestern geopolitical zone of nigeria according to the national population commission census ifedore lga has an area of 295km 2 and a population of 59256 the lga has 7 wards and there are 12 primary health centres which offer antenatal and post natal services deliveries immunization clinics and family planning services the target population for this study was women of reproductive ages between 15 to 49 years who were 1 week12 months postpartum and who were accessing child health services from three selected health centres in ifedore local government ondo state at the time of conducting this study the sample size was determined using the cochrans formula a standard normal deviate of 196 prevalence of use of modern contraceptives from a similar study in rural lagos state among postpartum anate and a margin of error of 5 were imputed into the formula to give sample size of 234 simple random sampling technique was used for selection of respondents the first stage was the selection of phcs which involved selection of 3 out of the 12 phcs in ifedore local government area using a simple random sampling method by balloting the second stage involves selection of respondents by systematic random sampling method the sample size was divided equally across the 3 randomly selected phcs thereby allocating 72 participants to each phc the instrument used in this study was a selfstructured questionnaire which was divided into four sections section a assess the sociodemographic data of the respondent while section b assess the level of knowledge of postpartum women on family planning section c assess the level of awareness of postpartum women on family planning section d determine the level of utilisation of family planning among postpartum women and sections e identify the factors influencing postpartum women for utilizing family planning at postnatal clinic the face and content validity of the instrument was ascertained by experts of tests and measurement and nursing the pilot study was conducted among the postpartum women attending clinic at the general hospital igbaraoke ondo state questionnaire was administered to twentythree postpartum women being ten percent of the total population to ascertain the reliability of the instrument data collected were analysed using kuder21 which yielded reliability coefficient value of 087 prior to data collection the participants were addressed on the purpose of the research and a verbal consent was sorted from each of the participants the research was carried out on the major clinic days with about 23 visits so as to meet up with the target sample size data collection was done by the researchers each participant was given a questionnaire to fill which comprised their sociodemographic variables assessing their level of awareness utilisation and factors affecting utilisation of family planning services the questionnaire was sorted manually after they have been properly filled by the respondents analysis was done using the 27th version of statistical package for the social sciences and findings were properly represented using percentages tables while the hypotheses generated were tested using chisquare at 005 level of significance table 2 shows that majority of the respondents 199 heard about family planning from health personnel in hospitals and health centres 18 of the respondents heard from friends 2 of the respondents heard from the televisionsradio 3 of the respondents heard on the internet while 1 of the respondents heard from other sources objective 2 common methods used by respondents for family planning at ifedore local government ondo state table 3 revealed that 12 of the respondents use male condom 22 of the respondents use injectable also 77 of the respondents use implants while 16 of the respondent use pills method it can be deduced from the analysis above that the prominent methods used for family planning by the respondents are male condom injectable pills and implants while other methods are rarely used objective 3 knowledge utilisation of family planning and perceived attitude of workers by respondents at ifedore local government ondo state table 4 revealed that 160 of the respondents have good knowledge of utilisation of family planning while 127 of the respondents said yes to the utilisation of family planning 151 of the respondents showed positive attitude toward utilisation of family planning based on the analysis in the table 44 it can be confirmed that the respondents in the study area have good knowledge and positive towards attitude utilisation of family planning hypothesis 1 there is no significant effect of factors influencing utilisation of family planning by respondents table 5 revealed that age is statistically significant different with pvalue of which is less than this means that people with the age bracket of reproductive age may tend to have family planning while those that are above or below may not border or concern about the family planning also marital status and religion were not statistically significant different however occupation and education were significantly different with the pvalue of and respectively it can be established from this fact that higher the level of education is the more social the person will be individual the secondary or tertiary education will know the benefit to drive from family planning the healthy family living going further from the analysis in the table 5 tribe does not statistically significant different while number of children of children is statistically significant different with pvalue of it can be inferred from this point that an individual with 6 7 children may not care or worry about the family planning while a couple with just only 1 or 2 children will be concerned about the family planning in order to prevent excess children that they will not be able to cater for in addition socioeconomic status revealed that there is significant different with pvalue of this shows that individual with high economic status will tend to acquire family planning while low economic status individual will disdain family planning finally access to services knowledge stigma and discrimination were also statistical significant different since pvalue is less than we reject h0 and then concluded that there is significant effect of factors influencing utilisation of family planning by respondents hypothesis 2 there is no significant relationship between awareness and utilisation of family planning since pvalue is less than which is the null hypothesis is rejected and then conclude that there is significant relationship between awareness and utilisation of family planning discussion of findings the majority of the participants a total of 156 respondents accounting for 667 of the sample fell between the age range of 18 to 30 years this aligns with the results reported by duru et al and essien et al but contradicts the findings of maitanmi et al obalase andjoseph out of the respondents 229 are married which aligns with akintoyes assertion that married women are mostly engaged in family planning furthermore the majority of the studys participants had secondary education rather than higher education aligning with the conclusions of duru et al and essien et al but differing with the findings of alhassan andjoshi et al based on the analysis above it can be inferred that the average age of the study population is between 18 and 30 years this indicates that the respondents are within the reproductive age range another important finding from the analysis is that a majority of the respondents are married this suggests that the respondents are wellsuited to answer the questions of this research study additionally the majority of the respondents belong to the yoruba ethnic group indicating that the study was conducted in a yorubadominated community the studys findings indicate that a significant proportion of the respondents exhibited a high level of understanding regarding family planning the majority of the participants concurred that family planning serves as a means to avoid pregnancy and facilitate the spacing of children these results align with the findings of duru et al maitanmi et al wodaynew and bekele and essien et al which also observed that most participants had a strong understanding of family planning methods however these findings differ from those reported by alhassan who found that participants only displayed a positive attitude towards utilising family planning services the study revealed a significant lack of utilisation of family planning among the respondents despite their considerable knowledge on the subject these findings align with previous studies conducted by maitanmi et al and obalase joseph only a small number of respondents engage in family planning more than six weeks after giving birth the most frequently used methods are implants injectables and male condoms which aligns with the findings reported by ackerson and zielinski duru et al joshi et al and anate et al the findings of this study demonstrate the positive and hindering aspects that impact the utilisation of family planning services several participants expressed strong support for family planning services due to their belief that engaging in occasional sexual activity could result in unplanned pregnancies which aligns with the findings reported by maitanmi et al on the other hand some participants cited the high cost of contraceptive methods as their reason for not utilising these services others expressed concerns about potential side effects additionally some participants believed that it was too early to start using family planning immediately or a few weeks after giving birth especially if they were breastfeeding and had not yet resumed their menstrual cycles furthermore the unavailability of husbands was identified as a barrier by certain respondents which is consistent with the findings reported by ayotunde et al additionally several individuals expressed that their religious beliefs did not prohibit the use of family planning services aligning with the conclusions published by maitanmi et al and abraham et al but contradicting the findings of seifu et al additionally certain participants expressed that their partners disapprove of family planning which contradicts the findings of seifu et al the study revealed that the husbands of the women agreed with the utilisation of family planning services and emphasised the involvement of family members in the utilisation of such services implication of the study the studys findings reveal a significant lack of utilisation underscoring the necessity for further investigation into the efficacy of intervention studies targeting the enhancement of fp service uptake while simultaneously addressing the several issues linked to service utilisation likewise a crucial factor in maximising the effectiveness of family planning services is the attainment of a comprehensive transformation in womens behaviour and attitude towards these services women empowerment and education are two effective strategies that enable women to have the necessary resources and agency to independently make decisions on the utilisation of family planning services likewise nurses midwives and other health professionals together with nongovernmental and religious organisations should engage in more proactive efforts to promote a shift in attitudes and thereby enhance the use of family planning services conclusion this study unveiled that women of reproductive age possess a commendable understanding of family planning services however despite this favourable level of knowledge the utilisation of such services remains somewhat inadequate the inadequate use of these services was attributed to variables such as low socioeconomic level religious beliefs and limited education nevertheless the level of understanding regarding family planning services remained somewhat inadequate the inadequate use of these services was attributed to variables such as low socioeconomic level religious beliefs and limited education nevertheless possessing a comprehensive understanding of family planning services might be regarded as a promising sign of positive outcomes in the future hence it is imperative to support initiatives that would foster the use of family planning methods among women recommendations the communitys education on the significance of having fewer families and the empowerment of women should be enhanced this may be achieved by promoting gender balance and strengthening the communitys attitude towards the role and status of women within households and society as a whole this will enhance their engagement in domestic decisionmaking encompassing matters pertaining to reproduction and the use of contraceptives healthcare providers should emphasise to postpartum women upon their arrival at the clinic that family planning may be initiated immediately after delivery

this study investigates the awareness and utilisation of family planning among postpartum women attending postnatal clinics in selected health centers in ifedore local government ondo state the objectives include determining sources of information examining common methods used and assessing knowledge utilisation and perceived attitudes of workers regarding family planning a descriptive design was employed and the target population comprised women aged 15 to 49 1 week12 months postpartum accessing child health services from three selected health centers the sample size of 234 was determined using cochrans formula with data collected through a selfstructured questionnaire validity and reliability were ensured through expert assessment and a pilot study analysis using spss 270 involved percentages tables and chisquare tests the findings revealed commendable understanding of family planning services among women of reproductive age although utilisation remained inadequate factors contributing to this included low socioeconomic status religious beliefs and limited education despite these challenges the study highlights the potential for positive outcomes in the future emphasizing the importance of comprehensive understanding of family planning services recommendations include enhancing community education on the benefits of smaller families and women empowerment promoting gender balance and emphasizing immediate initiation of family planning postpartum in healthcare settings these initiatives aim to address barriers and promote the use of family planning methods among women in the study area

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i introduction several dynamical phenomena are associated with the mobility of human beings pedestrians movement patterns 1 and associated behaviour synchronized behaviour such as flocking or herding 2 are some well known examples mobility of human beings is often motivated by some definite purpose and emergent phenomena such as segregation and migration may result 3 dynamical phenomena associated with movement of human beings and animals have attracted the attention of physicists as many of these can be mapped to dynamical physical systems for example pedestrians movements can be analysed using a social force model 1 and flocking phenomena can be studied in terms of the classical xy model 2 the segregation phenomena is fundamental in nature and seen to be present in the human society in different forms in a heterogeneous society consisting of different racial or cultural groups it is often found that people prefer to live in the neighborhood of people belonging to the same group 4 which results in a segregation segregation may occur due to different factors such as age income language religion color etc to achieve segregation in space one must consider the movements of the agents following certain rules a simple model of social segregation was proposed by schelling 5 6 7 long before the issue of residential segregation received serious attention 8 this model illustrates how an individuals choice of living with the neighbor of the same kind can lead collectively to segregation the model received attention from physicists as it was realised that its continuous analog in space and time corresponds to a dynamical model of solid or liquid flow 9 on the other hand it has similarity with magnetic models with conservative dynamics 1011 and also the dynamical phenomena of phase ordering 12 later several variants of the schelling model were studied in 13 a unified mathematical framework was developed for a broad class of models of the schelling type in most of the schelling class models agents occupy sites of a two dimensional grid in 14 it was considered that the agents occupy districts rather than sites on a two dimensional grid which improves social realism of the model in the original schelling model a utility factor is defined based on the fraction of opposing neighbours if the latter is greater than 12 the utility factor is defined to be zero an unsatisfied agent with zero utility tends to move to a vacant site in the neighbourhood only if that makes the utility factor larger however it was shown later that this leads to segregated clusters which are rather small in size it was found that the system can reach a segregated state where large clusters are formed provided agents are allowed to move even when the utility remains same 91516 this is called the unconstrained case the configurations generated in this way are very similar to those occurring in the phase separation dynamics whether the dynamics is constrained or unconstrained is a major concern in the schelling model in 16 both the constrained and unconstrained cases were considered in one dimension and it was shown that the constrained model shows nontrivial static properties characterised by the presence of a symmetry breaking phase transition on the other hand in the unconstrained model the dynamics exhibit coarsening as in isinglike models with nonconserved order parameter also it was shown in 9 that the constrained case corresponds to solidlike flow while the unconstrained case mimics the flow of liquids in the present paper we consider continuous values of the utility factor and show that even subject to the constrained rule it is possible to obtain good quality segregation ie segregated clusters are larger in size this is comparable to the unconstrained case with discrete utility factors the case of continuous utility was considered earlier in 1718 with added degrees of freedom and the effect of continuous utility alone was not obvious in 19 utility was regarded as a general function of f but only the case where f 12 was taken and a special form of the utility function was used in 9 where the mapping of the schelling model to a physical model in continuum had been made the utility factor was also taken as a continuous function however results were obtained only for the case where it has a step function like behaviour the reason for considering utility as a continuous valued variable is twofold first it gives an idea of the degree of mismatch between the agent and their neigbhours secondly it provides a greater mobility to the unsatisfied agents as they can now move to a different location even when utility does not become positive necessarily but definitely improves this is close to reality as it is not possible to attain an ideal state always especially in a single step so in an indirect manner the movements of agents become less constrained in the continuous case apart from studying the segregation phenomena and related phase transitions certain dynamical features are also studied for the two models in section ii we have defined the models and the quantities calculated and section iii gives the details of the simulation in section iv results are discussed section v contains study of the correlation function and section vi contains summary and discussions ii models and quantities calculated first we describe the schelling model with discrete utility factor where the agents belonging to two different groups are located on the sites of a chessboard some sites are left vacant the fraction of vacant sites is denoted by the dilution parameter p the neighborhood of an agent comprises eight nearest sites the agents are able to relocate according to the fraction of neighboring agents belonging to their own group an agent located at the center of a neighborhood where the fraction of neighbors of opposite group is greater than a predefined tolerance threshold f will try to relocate to a neighborhood for which f is less than or equal to f the agents for which f ≤ f utility factor u is defined to be equal to 1 and the agent is said to be satisfied otherwise the agent is unsatisfied and utility factor is 0 in this paper we have introduced the utility factor as we check how the segregation is affected by varying the dilution parameter p and tolerance threshold f in these two models a similar study was done in 20 with u taking discrete values only we take a l × l lattice with a fraction p of sites empty at random agents belonging to two different groups occupy the rest of the sites randomly in the beginning if n a and n b denote the number of agents belonging to two different groups then n a n b n n a n2 n b n2 and n l 2 the fraction of neighbors belonging to the opposite group f is calculated by dividing the number of opposing neighbours by the total number of occupied neighboring sites for example if 6 neighboring sites are occupied and 2 of them belong to the opposite group then f 1 3 the total number of neighbors is a variable and can vary from 0 to 8 if the total number of neighbors of any agent is 0 then the agent is taken as satisfied ie they have a positive utility u f f segregation models are known to exhibit phase transitions one can vary factors like the threshold value f the dilution factor p size of the two groups etc to investigate the presence of a critical value belowabove which segregation can occur as already mentioned in 16 a phase transition in the constrained case was observed as the dilution factor was increased in the unconstrained model considered in 20 where satisfied agents could also move it was found that by varying p and f a phase diagram can be obtained there are two transitions for very small f the states are frozen increasing f one can get a segregated state while above a critical f a mixed state exists in the present model we calculate two important quantities the first is φ the fraction of agents with negative utility if m denotes the fraction of population with utility u φ u 0 m φ is zero for f 1 trivially the other quantity is the average utility defined as u f f the average fraction of opposing neighbours f avg helps in understanding qualitatively whether segregation is reached one can define s 1 f avg to be the segregation factor the larger is s the better is the degree of segregation three types of states may occur the frozen state where φ has large nonzero value and s is very close to 05 this situation is analogous to the jamming transition 14 in segregation model in which large numbers of agents remain stuck in unfavorable states as f is made larger s may increase if s is very close to 1 and φ is negligible one may call that a segregated state for even larger f s will decrease from its maximum value while φ 0 eventually for f 1 s 05 and φ 0 which is of course a mixed state our goal is to study whether there are sharp or smooth transitions from one state to another as f is increased we have also calculated some dynamical quantities related to the motion of the agents the first is the persistence probability p move which is defined as the fraction of agents who have not moved till time t another quantity calculated is the mobility factor defined as the average distance travelled by the agents denoted by d this is the average euclidean distance between the initial and final positions of the agents these two factors have not been studied in the context of segregation models earlier to the best of our knowledge iii details of simulations in the initial configuration the n agents belonging to the two different groups are homogeneously distributed among the l 2 sites a site is chosen at random at every time step if the chosen site is occupied then it is tested whether the agents are satisfied or not if the agents are satisfied they stay at their present site otherwise they select one unoccupied site at random from all sites that are unoccupied at that moment we assume that the list of unoccupied locations is available to the agents the unsatisfied agents move to the randomly chosen empty site provided they become satisfied there or the utility factor increases otherwise they stay at their present site only one such attempt is allowed dynamics stop when the system reaches an absorbing state ie there is no change in the dynamical quantities measured an absorbing state is always possible here we have used p values from 002 to 06 and 0 f 1 for each set of parameters 2500 initial configurations are used over which the relevant quantities are averaged we have used different l values results for l 20 30 and 50 are presented iv results a steady state behaviour and phase diagram model a we have studied the time dependence of various quantities defined in the last section and observed that they all reach a steady state value in time we first discuss the behaviour of φ as a function of time we find that in general for small f φ reaches a nonzero saturation value but for larger values of f the saturation value of φ becomes zero plotting the saturation values we find that there is a critical value of f f c where φ decreases to a negligible value discontinuously hence this critical value separates two regions of φ 0 and φ 0 f c depends on p next we discuss the behaviour of u in the steady state as can be seen from fig 2 this goes from a negative value to a positive value as f is made larger and crosses zero at a value of f ≃ f c in analogy with magnetic or liquidgas phase transition one can interpret the u 0 point as a coexistence point thus f c acts as a field which separates the two regions with u 0 and u 0 much like an external field in magnetic systems below the critical point for complete characterisation of the system the variation of the saturation value of s the segregation factor as a function of f is studied we find that s sharply increases from s ≈ 05 to a large value at a value of f ≃ f c hence we find a region where φ 0 and s ≈ 05 which we identify as the frozen state as φ drops sharply to zero at f c and s also shows a sharp increase at the same point one can conclude that a transition between a frozen state and a segregated state occurs at f c since there is hardly any finite size dependence in the data and all the quantities show sharp changes at f c we conclude that the transition is first order in nature apparently no sharp transition occurs between the segregated state and mixed state as s decreases for larger values of f approaching ≃ 05 as f → 1 monotonically however we note that s remains almost constant for a range of value of f before decreasing this suggests there may be another transition occurring at f f c between a segregated state and a mixed state as it is difficult to identify the second transition point we define a transition point where s becomes less than 09 ie we define the state as segregated when s ≥ 09 based on these findings we show the transition points between the three different phases in the p f plane for model a in fig 4 we next present some typical snapshots in fig 5 to show the effect of increasing f and the quality of segregation the snapshots show the steady states for p 01 and p 03 for a small value of tolerance threshold f the probability that an agent is unsatisfied is quite large however the probability that a favourable site be found by relocation is also small at small f for a more detailed discussion see section vi thus the initial grey picture where the agents of two groups are mixed up remains almost unchanged ie frozen in time as f is made larger fewer agents will be unsatisfied however the probability to find an empty site which will satisfy the agent is larger and the system will undergo a time evolution and the steady state picture will show finite sized domains of agents of the same group making s 05 for smaller value of p the effect will show up for a larger value of f if f is made even larger the need for relocation becomes less since now almost all the agents are satisfied although some agents will move the cluster sizes will be much less this is apparent in the figures for f 07 we note that the snapshots are very similar to those of the constrained schelling model which is consistent with the fact that model a effectively uses binary utility factors the cluster sizes even in the so called segregated state are small with the interface showing a lot of roughness model b in model b also we have studied the time dependence of the relevant quantities and observed that they reach a steady state value in time the most striking result in model b is that a nonzero value of φ is obtained only for rather small values of p for any value of f 0 in fig 6 we have plotted φ as a function of time for p 01 as in model a here also φ reaches a nonzero saturation value for smaller f and goes to zero for larger f although the plot of saturation values of φ with f lacks smoothness there are two clear indications first the saturation values of φ are rather small even for small values of f secondly there is appreciable system size dependence in fact we find that φ decreases with system size and as the φ values are already 01 for l 50 one can conjecture that φ would vanish for any f in the thermodynamic limit see fig 6 inset the behaviour of u in the steady state is also completely different from model a and supports the conjecture that φ vanishes for all f and p in model a the steady state value of u goes from a negative to a positive value sharply at a particular value of f which is dependent on p but in model b the steady state value of u is always positive no matter how small f is and it shows finite size dependence u is larger for a larger system size although above f ≈ 05 system size dependence is negligible hence the value of f c is simply equal to zero for model b physically this implies that there is no frozen state in model b in fig 8 we have shown the behaviour of segregation factor s from this figure we can see that the steady state value of s is much larger than 05 even for small f and remains almost constant over a considerable interval of f before decreasing the decrease for large f values is due to the same reason as in model a the agents are satisfied when f is large even with a considerably large value of f s also shows appreciable system size dependence it increases with system size and approaches 1 in the thermodynamic limit for smaller values of f we show in fig 9 the transition points between the segregated and mixed phase for model b since in model b there is no frozen state there is only one transition line for nonzero f as in model a there is no sharp transition between the segregated and mixed state and the boundary between the segregated state and mixed state is obtained using the same criteria as in model a typical snapshots of the steady states for model b are shown in fig 10 the steady state snapshots are almost identical in nature to those occurring for the unconstrained case with discrete utility factors 9 and hence we find that even with the constrained case it is possible to obtain segregated states with large cluster formation provided the utility factors are continuous the picture for small f is very similar to that occurring in phase seperation dynamics we note that the cluster sizes are much larger compared to those in model a especially for small f where s is close to 1 also the interfaces are much more smooth and the overall scenario is similar to liquid flow dynamics even for larger values of f where the mixed state occurs the cluster sizes are apparently larger compared to model a b results related to mobility we have evaluated persistence probability and average distance travelled in both the models model a we have plotted the persistence probability p move corresponding to movement of the agents as a function of time in the inset of fig 11 the main plot shows the steady state values which drop to a considerably smaller value close to f c there is also a nonmonotonic behaviour of the steady state values as a function of f the plots support the picture that for small p the agents show very little movement leading to frozen states once again system size dependence is negligible the plot of average distance travelled by the agents d against f are shown in fig 12a from this figure one can see that the average distance moved by the agents suddenly increases close to f f c and then slowly decays with f model b for model b the persistence probability corresponding to movement of agents with time is plotted in fig 13 we have plotted the steady state value of p move for a rather small value of p 005 and have found that there is a monotonic increase as a function of f also the steady state probability is fairly low for f 04 signifying the agents have high mobility considerable system size effects are present for larger systems the persistence probability decreases for f 04 in fig 12b the average distance travelled by the agents against f is plotted there is an overall tendency of a slow decay as f is increased the behaviour of p move and d can be easily explained as f is made larger the need to move decreases as the agents become more tolerant and hence there is less movement making p move large and d small this is true in both the models v correlation we have calculated the correlation as a function of distance in the steady state to have an idea of the cluster size the latter is a measure of the quality of segregation if the ith site is occupied we have assigned values s i ±1 corresponding to the two different groups if it is empty s i 0 correlation between two sites at a distance r is defined as c s i s j where r is the euclidean distances between the ith and jth sites vi summary and discussions in this paper we have defined continuous utility factors in the constrained schelling model with nonlocal jumps we have introduced utility factor as u f f where f is the tolerance parameter and the fraction of opposing neighbor is f the agents are satisfied if u has a positive value or zero thus the utility factor not only carries the 20 as only movement of unsatisfied agents are considered although in both models nonlocal jumps are allowed model a shows a frozen state and a sharp transition to a segregated state at a nonzero value of f the segregation factor s remains close to 1 before decreasing slowly to 05 the value corresponding to a completely mixed state defining the segregated state to be that for which s 09 one can obtain a boundary between the segregated and the mixed state the most striking observation for model b is that here the frozen state does not exist in the thermodynamic limit in contrast to model a and unconstrained model with discrete utility 20 one can justify the presence of the frozen state in model a for small f in the following way let the two groups be labelled x and y let at a particular vacant site all the neighboring sites be occupied and y be the number of y type neighbors now the probability that an x type agent which is unsatisfied at its present position will jump to this particular vacant site is 8f y0 8 y p 8 in model a if f is very small then only very few terms will contribute to the sum hence the probability is rather small and very few unsatisfied agents will be able to move in a finite time for small f and p thus for all practical purposes this makes the majority of the agents stay in their present unsatisfied state in model b the probability that an x type unsatisfied agent with y ′ number of y type neighbors in its present position will jump to this particular vacant site is in model b the segregation factor remains very close to 1 from f 0 to a finite value of f and then decreases slowly to 05 one can obtain a boundary between a segregated state and mixed state as in the case of model a since model a is identical to the constrained schelling model with discrete utility it is not surprising that only small clusters are generated in model b large clusters are formed similar to the unconstrained model this is confirmed from the calculation of the correlation as a function of time of course a rigorous calculation of cluster sizes as a function of the parameter f and p will be able to distinguish model a and model b more quantitatively and will be reputed in a future publication 21 other features like persistence probability p move and average distance travelled d also show sharp differences in the two models in model a these quantities are largely affected by the presence of the phase transition at f c there is nonmonotonic behaviour in model a we may add the remark here that although the behaviour of p move and d have clearly different behaviour in the two models the variation with f in model a for f f c and in model b for f 0 is quite similar for both quantities note that in these two regions u 0 and thus the agents are happy on an average which seems to be the relevant factor determining the trends of p move and d it will be interesting to compare these findings with real data if available in future studies in a way model b is a semiconstrained model as movements are less restricted here and perhaps it is not entirely surprising that the segregation occurs here to a larger extent however the absence of the frozen state is a complete surprise the present model with continuous utility shows that moves which make utility larger but not necessarily positive helps in attaining segregated states more effectively in contrast to the unconstrained model this is a more realistic strategy as in the unconstrained model the tendency to move keeping the utility factor unchanged does not seem to be practical on the other hand in the study of the constrained model b we get the important message that even if one cannot achieve the ideal state in a single step it is worthwhile if an action brings one closer to it

we consider the constrained schelling model of social segregation in which the utility factor of agents strictly increases and nonlocal jumps of the agents are allowed in the present study the utility factor u is defined in a way such that it can take continuous values and depends on the tolerance threshold as well as the fraction of unlike neighbours two models are proposed in model a the jump probability is determined by the sign of u only which makes it equivalent to the discrete model in model b the actual values of u are considered model a and model b are shown to differ drastically as far as segregation behaviour and phase transitions are concerned in model a although segregation can be achieved the cluster sizes are rather small also a frozen state is obtained in which steady states comprise of many unsatisfied agents in model b segregated states with much larger cluster sizes are obtained the correlation function is calculated to show quantitatively that larger clusters occur in model b moreover for model b no frozen states exist even for very low dilution and small tolerance parameter this is in contrast to the unconstrained discrete model considered earlier where agents can move even when utility remains same in addition we also consider a few other dynamical aspects which have not been studied in segregation models earlier

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introduction religious beliefs have always been the major motives for human behavior despite the different philosophical and intellectual positions on religion due to the great importance of religion in directing human behavior and with the emergence of the global threat covid19 pandemic there is an urgent need for a new religious discourse that surpasses the metaphysical approach that deals ontologically and that heads into a theological debate to employ religion to serve the humanity to live in coexistence peace and harmony mans need for religion is not linked to a specific time rather it extends to all times and eras as a man still invokes religion in the face of rising challenges one of the most serious of these challenges is epidemics and diseases the invocation of religion in this regard infuses a moral spirit that helps in facing the dangers of the disease and its negative repercussions which are extremely dangerous at all levels religion is the main source of the provision of moral values and ethics for humans the two traditions christianity and islam enjoy a high moral heritage the present study discusses the employment of the christian and islamic religious discourse in the face of epidemics especially covid19 this pandemic forced humanity to enter an unprecedented era with new precautions that our current time is called the covid age this paper is an attempt to reveal different aspects of islam and christianity by reviewing the moral system of the two religions at different levels to reach an integrated perception of how to deal with crises and calamities in light of an ethical system that seeks to preserve human beings regardless of their genders origins or religions the importance of this article lies in its attempt to analyze the impact of the pandemic on societies and the fluctuations it caused in the various fields of life in the economic scientific psychological or security fields etc it also shows the importance of invoking islamic and christian morals to confront the pandemic in addition it seeks to explore the effect of false religiosity on the spread of the pandemic and the increase of fear and panic in communities and to explain the importance of raising awareness of such false religiosity and finding the necessary solutions to reduce it morals have a great impact on the lives of people and nations when crises and calamities occur moral influence is not limited to one religion rather all religions seek to adhere to and apply them in life regardless of the different means and methods they follow the coronavirus which began to spread from china and soon spread to all countries of the world and its repercussions affected various aspects of political economic and social life morality in islam and christianity played a positive as well as a negative role in the spread of the pandemic in several societies morals were also the subject of controversy among the followers of these religions concerning how to apply them in dealing with the pandemic hence this article attempts to explore the relationship between morals in islam and christianity and their role during the pandemic in various areas of life more specifically the article attempts to answer the following main question how was islamic and christian morality employed to confront the pandemic under this main question there are some branching questions what is the impact of the pandemic on societies how did this impact affect different areas of life has the pandemic led to the emergence of a new moral crisis the question of morality in christianity and islam comes at this particular time to shed light on these religious values and to employ them in the face of this pandemic and overcome it at a time when all materialistic approaches have failed miserably in addressing the dangers of this pandemic therefore this study seeks to reach a satisfactory answer to this question can the moral system in islam and christianity succeed in preserving human life in light of the corona crisis covid19 a global threat to humanity the human race has encountered throughout history the outbreak of many deadly epidemics and pandemics that wiped out entire peoples and in some cases changed the course of history the world today is witnessing an unprecedented epidemic crisis perhaps the most dangerous and influential epidemic in modern history we start with some definitions of terms an epidemic is defined as every highly contagious disease that spreads quickly from one place to another infects humans animals and plants and is usually fatal like the plague a pandemic on the other hand is different from an epidemic in that it spreads across large geographical areas encompassing continents or sweeping the whole world an epidemic is a disease that spreads widely in a specific area and within a specific time if the disease spreads throughout the world it is then called a pandemic 1 the world health organization defines coronavirus as the emerging covid19 virus of the corona family it was first identified in a number of asymptomatic patients in wuhan city hubei province china most of the cases were related to the seafood and animal market there the first outbreak of this emerging virus was recorded on december 31 2019 2 thus covid19 is one of the biggest health challenges facing humanity in the contemporary world as it has caused injury and death to millions of people it would therefore be a mistake to describe this challenge as only a health tragedy rather it is a largescale global human tragedy that has affected all areas of life it has caused social economic political and psychological crises that are still yielding negative effects on all countries of the world this pandemic will undoubtedly lead to the reformulation of the present social economic and political systems this transformation will also lead to a radical change in the way humans interact with the environment in which they live the catastrophe is not only in the huge numbers of injured and the dead but also in the enormous complications of the pandemic and the congestion occurring in various aspects of life the following are some of these catastrophic effects i effects on the global economy with the emergence of the crisis the global economy witnessed a noticeable recession which increased with the expansion of the pandemic the pandemic led to the disruption of economic facilities as a result of quarantine social isolation and curfews which were precautionary means to protect against the epidemic this affected the global economy significantly indicators of employment industrial production and services show that the recession in economic activity will be unpredictably severe according to the international monetary fund the global economy recessed in april 2020 at a rate of 3 the rate is expected to rise to 7 if the crisis continues in 20212022 we can expect the severity of this recession if it is compared to a recession rate of 1 in 2008 during the global financial crisis it will take a long time to compensate for the economic losses depending on the extent of control over the pandemic3 the level of supply of materials and intermediate products has decreased globally from 52 to 48 during the previous ten years4 the pandemic caused this percentage to decrease as well this decrease in the level of supply of goods severely affects the vital areas of large as well as small goods in the global economy indicators show that most of the recession in the global economy caused by the pandemic will result from the provision of materials and goods globally it is expected that the pandemic will lead to more cautious measures and will accelerate the change of economic policies as happened in some countries after the financial crisis with the spread of the epidemic a sense of the unfair distribution of wealth was heightened as a result of liberalism fears of high levels of unemployment lead to doubts haunting employees concerning their sustenance and sources of income the decrease in the real income rate of some individuals will increase the number of people living below the acute poverty line which is expected to rise to 49 million the debt ratio will consequently rise also 5 ii effects on the educational sector educational institutions have the greatest role in the advancement of societies as they are the symbol of knowledge culture and innovation the leader of change in societies and the guarantee for achieving development and progress for people the effects of the pandemic swept over all aspects of life in the world and the education sector was no exception in fact it was the most affected sector audrey azoulay directorgeneral of unesco said we have never witnessed such turmoil in the field of education with the speed and size of educational disruption resulting from the closure of schools and universities in order to avoid the spread of the virus among its members governments sought to provide distance education for their children where students stay at their homes away from schools and universities and learn remotely 6 according to unesco reports the pandemic has caused 16 billion children and youth to drop out of education in 161 countries around the world this means that an average of 60 to 80 of students drop out of schools and universities many countries closed down schools and universities which in turn affected education badly 7 while some countries resorted to lectures and lessons recorded on internet platforms other countries suspended study until further notice due to the shortage of information technology infrastructure questions about how to align classes and schedules are still troubling educators some sectors succeeded in covering their schedules through online platforms while it was not possible for others as a result elearning has been used as an alternative to physical education in most countries of the world although recently the educational system restored part of its facetoface nature still some countries use elearning while others opt for blended learning by integrating traditional learning with elearning however elearning faces many challenges that include for example the lack of adequate educational equipment for all students the lack of a powerful administration that organizes and manages the elearning process in some education sectors in addition to the shortage in electronic curricula for all courses not to mention the unavailability or weak connection of students internet networks or their frequent interruption during the lesson there are other challenges and problems at the level of students teachers and parents thus the current challenge today is to address the negative effects of this pandemic and its repercussions on learning and teaching and to direct efforts to benefit from this experience in reviewing the educational process and improving its quality iii effects on the psychological security as the number of covid19 victims increased with no foreseen ceiling the pandemic caused a state of panic fear and terror that gripped societies for a long period there was no proven treatment or vaccine to control the spread of the pandemic even with the advent of the vaccine security and psychological reassurance for many people were not achieved due to the emergence of a large number of rumors about the dangers of vaccinations since the onset of the pandemic and till now social distancing and lack of personal encounters is the best solution to stop the virus as the infection is airborne by inhaling the air through the mouth or nose or touching affected surfaces and then touching the eyes mouth or nose however this solution had an adverse effect on the mental health of individuals and societies which left humanity confronting great existential anxiety that threatens humanity as a whole the adverse effects of social distancing varied with the presence of social media networks which reduced the feeling of isolation and anxiety achieved a balance between work and family affairs and led to a change in the lifestyle within the same family parents tried to strike a balance between working remotely and paying attention to their children learning remotely while this divergence strengthened some family relationships it also exacerbated differences in other families the level of international media interaction with the pandemic varied among various media broadcasts some caused panic and increased terror with the outbreak of the pandemic as they saw the virus as a war waged to control the population of the world or a commercial project to bring profits for pharmaceutical companies from tests and vaccines some thought it is an attempt to break chinas economy and control it or advocated the conspiracy theory that bill gates has a program that seeks to control humans through eportals whereby covid19 was manipulated as an excuse to implement his program 8 these and other rumors increased the adverse effect on the psychological and mental health of individuals who believed in these rumors even after they turned out to be hoaxes this is because these rumors fulfill the pentup desires and hopes of some who could not actually achieve them after all they lack the means to do this 9 for some the pandemic has become a new phenomenon and an excuse for the suppression of human rights as authorities use their power to implement many different restrictions to keep the virus under control some governments have taken strict measures to monitor and trace the infected and their contacts china used facial recognition technology for the same purpose while israel uses technology to extract information from the phones of the infected or the potentially infected 10 some countries such as denmark 11 have also implemented a compulsory vaccination project for all citizens undoubtedly isolation social distancing spreading and circulating conspiracy theory rumors lead to more complicated psychological problems and badly affected the psychological and mental health of people 12 psychological security is a basic and necessary need in a persons life that is acquired through interaction with the environment around him throughout his life studies indicate that a persons psychological security is endangered and threatened when exposed to psychological and social pressures that are beyond his capacity to endure 13 covid19 pandemic has undoubtedly caused many adverse psychological effects including the fear of infection and the pressure of home isolation this pandemic forces us to reconsider many policies and review many priorities to avoid similar crises in the future or even to turn them into a blessing that is used to immunize future generations from such crises despite the crises and dangers life keeps going on this pandemic will pass but its effects will be devastating this should motivate us to exert efforts to avoid similar crises it is imperative that humans keep in mind that the scramble for industrial progress and armaments may lead to even greater harm and counterproductive results the proof for this is that one small virus succeeded in bringing the entire world into quarantine and isolation while weaponry and industrial and technological development have not helped in confronting it this is a valuable opportunity to rethink the future of the world and work on the positive exploitation of its resources by transferring a large part of the economic and financial potential used in the arms industry and investing it in education health and scientific research however this cannot be achieved without a sense of belonging cooperation and sharing with others here the importance of awareness of the humanistic dimension comes into play invoking the longabsent moral dimension in dealing with the pandemic will aid humans in building a sound and secure future for the coming generations to attain all the aspired goals the moral crisis covid19 pandemic emerged in a global world that was supposed to move towards the establishment of international organizations that reflect more global human solidarity in the economic social and cultural fields of life and that establish the bases of an economic and financial system in harmony with the functions of the contemporary global organization that seeks to meet the international humanitarian needs14 the question that is at stake now is have these global organizations and their affiliated bodies been able to confront this global threat did the global order and the international organizations confront this danger there is an indisputably abject international failure in the face of this pandemic this failure is not limited to national states only but is extended to the international organizations and bodies that were established during the twentieth century and represented this new international order in most cases governments and international organizations seemed crippled to keep pace with this challenge covid19 brought about tremendous and radical changes in international relations which revealed to the world the ills of the new international order the health crisis turned into a global moral crisis the ordeals and calamities uncovered the inner nature of peoples and nations western countries out of fear of the epidemic regressed to the time of maritime piracy and armed robbery many countries that used to call for human rights in life and coexistence repudiated these values and declined the practice of maritime piracy such as the czech which intercepted a ship loaded with medical masks heading from china to italy italy by its turn pirated a ship bound for tunisia loaded with medicinal alcohol it is as if covid is recalling the imperialist motto survival for the strongest 15 it seems covid19 has uncovered the moral crisis that befell international relations showing their concern for materialistic interests only the proof of this is the disintegration of major western bodies such as the european union whose fragility and ineffectiveness was evident in its first real test italy one of the active countries in the eu repudiated it and raised the flag of china instead of the eu in appreciation of its assistance in facing the crisis after each european country isolated itself from the other member states each became concerned only with its citizens who reside within its borders 16 the united states diverted the course of a shipment of masks that was destined for the german police and bought medical supplies at exorbitant prices to cut off the way for other countries to get these supplies about 200000 n95 masks which are personal protective equipment used to protect hospital workers from infection were diverted while airborne to the united states as they are transferred between planes in the thai capital bangkok this act was described as modern piracy france accused the united states of buying masks that france had ordered from china while on the tarmac of chinese airports and before the planes took off sweden accused france of seizing medical supplies coming from china canada issued a warning to the us against restricting international trade in medical materials and equipment amid the outbreak of the coronavirus pandemic 17 based on the above mentioned the superpowers in the international order are witnessing heated competition imposed by the crisis instead of concerting efforts and enhancing cooperation in the meantime fears are heightened that this competition may slip into the manipulation of the medical equipment networks and affect the fair distribution of the vaccine which may have severe consequences for poor countries this is what the world health organization described as the shocking imbalance in the distribution of covid19 vaccines between rich and poor countries and called for a more equitable distribution of the vaccines 18 16 ibid191 17 the moral crisis is manifesting in employing the theory of the clash of civilizations in dealing with the pandemic and ignoring the rights of human coexistence and peace among human beings discussions have started about the upcoming conflict between the us and other new superpowers as some analyses indicate that the usa may engage in a military conflict with china after the pandemic ends in order to force china to discuss the conflicting international relations and global issues prominent among which are the economic issues and areas of influence 19 there is no doubt that such behavior leads to the destabilization of societies which is contrary to both islamic and christian morality which calls for compassion sympathy with others and the rejection of selfishness through participation during crises god honored man with the blessing of freedom of choice distinguished him with reason and commanded him to use these blessings to reach wise decisions by applying these blessings and adopting the islamic and christian morality that calls for unity cooperation and solidarity we can resolve these conflicts that have spread in the world due to the pandemic and reduce the unnecessary panic that has spread in our communities the pandemic has played a major role in the awakening of the world as it has aroused muslims to think about their brethren who have been displaced due to wars and persecutions the world is calling for a return to the morals that emphasize defense mercy justice affection and thinking about others which are morals that islam calls for the qurān states the believers are but brothers q 4910 similarly christianity also urges in addition the pandemic reminded many people who live without fear and enjoy comfort in normal daily conditions that they should not take life for granted at all they should not forget to remember god worship him and thank him for his blessings and to keep on the right behavior and the straight path it was said that sūrah alfātiḥah includes four fields of knowledge namely the knowledge of what achieves perfection which is the morals the highest of which is to reach the state of eternal presence with god to resort to the virtues of monotheism and follow the path of righteousness to those the sūrah referred to by mentioning the path of those you have blessed not those who deserved your wrath nor those who went astray these are morals that christianity also promotes ephesians 5 79 evoking moral values in christianity and islam to confront the pandemic one recurring question is always posed regarding the effective role that religion can play in handling the risks of global crises unfortunately one prevailing view underestimates such a role in confronting hardships the prominent work of the father of modern christian theology philosopher and biblical scholar friedrich schleiermacher in the philosophy of religion in his book on religion speeches to its cultured despisers issued in 1799 in this book his main concern was to restore to religion its high status and attack the harms it suffered in the enlightenment by romantic sceptics and despising intellectual secularists 20 schleiermacher after this book became one of the greatest theoreticians of religious pluralism and religious tolerance religion for him is not viewed from a purely metaphysical angle as just a way of thinking a belief or a way of contemplating god and the world rather religion incorporates also a means of action an amazing desire and love and a distinctive pattern of work and behavior 21 as religious beliefs express opinions about god and the world they also direct life through behavior and action and define the dimensions of mans role in the universe 22 therefore the philosophical mind since its formation has been paddling in the spaces of logos and myths the conflicts of god and the universe and theology and politics resulting in various approaches and diverse opinions human nature is undoubtedly extremely complex as it includes various dimensions in its composition those who have a single perspective regarding human nature would definitely err and go astray religion in modern academia has become a rich subject for many schools of thought in the humanities including psychology sociology ontology and anthropology the relationship between the public sphere and religion has always been controversial almost all political perspectives are shaped by a religious belief regardless of the degree of secularization of the country the religious factor cannot be ignored in directing major political decisions regardless of their negative or positive impact john coleman does not hesitate to acknowledge that the biblical scriptures are the most powerful and persuasive symbolic sources for public ethics in the united states today regardless of whether the influence of this religious heritage may be conscious or unconscious the morality that spencer used as the proof of religion recurringly reveals its divine source as the original human inclination for a moral obligation is part of the human nature created by god according to kant this inclination is the essence of almost all aspects of religion the essence of religion is not rituals or ontological systems rather it is the fulfillment of the duty to respond to the call of conscience which is the very call of god kant made this statement about morals after the heated debate in the 18 th century in the west about the essence of religion on the other bank of the river we find feuerbach in the 19 th century who declared that religion is not the source of morals rather the moral feeling transcends religion especially when he compared between love and faith he explains that the human component by nature reflects morals which are the highest qualities in man or it is a man in his ideal perfection such perfection that religion cannot achieve feuerbach exalts morality over religion and makes it the pathway to prove the divine however he does not reject the mutual exchange between morality and religion in constructing and influencing moral actions 23 with this influential presence of religion in human behavioral actions religion is always recalled to play its role in correcting guiding and reinforcing human actions through sustaining common values and bridging the gap between human beings the world is certainly in dire need of invoking religion and its moral components in the face of this dangerous epidemic that is threatening mankind invoking the moral role of christianity and islam in confronting the pandemic in all aspects of life whether negative or positive religion occupies the highest place in dealing with these ordeals in the pandemic crisis religious institutions played a major role in dealing with the pandemic the religious message achieved a great victory in preserving human life it also reinforced the moral and human dimension in societies where the importance of science and knowledge to confront the pandemic was emphasized the religious moral message helped people to take rational actions as it supported the lockdown on worship and religious rites gatherings and called for respecting and observing the legal precautious procedures to preserve peoples lives surveying different societies during the pandemic communities can be classified into two categories the first category those who are weak in faith the reason for this is due to the individuals adherence to a system of values that relieve his fear and endurance however with the passage of time and by the increased psychological pressure accompanying the spread of the pandemic doubt starts to infiltrate peoples beliefs in these values some would wonder why does god the almighty send us this pandemic while we believe in him and worship him a person may feel confusion between his desire to protect his values beliefs and religion and his doubts regarding the power of religion to protect his life this often happens when rumors are at large or due to a lack of information about the pandemic especially with the spread of social media and its exploitation by some extremists who incite fear and panic in societies all this in turn leads to weakening faith and belief among communities the second category those whose level of faith religiosity and practice of religious rites increase as the crisis elevates as they continue contemplating the role of religion in protecting them from the epidemic so that they generate ideas that make them believe that religion faith and returning to god will protect them from the epidemic they do so because they view the epidemic as an affliction a trial and a reminder from god to them what we propose is that religion works in human life in different ways religion does not conflict with science as religious scholars acknowledge the significance of the experimental sciences and acknowledge their results and workable solutions to crises and problems facing humanity this is noticeable in the approval of religious scholars of the medical measures that were taken to confront the pandemic they served as a supportive force for governments health efforts and legal forces whereby they called on people to abide by the laws and follow the precautionary measures they urged people to reject rumors fabrications and falsehoods that were spread by some institutions of different agendas this is evident in the positions taken by the official religious institutions ministries and endowments regarding the covid19 pandemic in a way that reflects the true complementation between science and religion official religious figures were at the forefront of those who responded to the states precautionary measures religious gatherings were prohibited from performing religious rites and rituals in mosques or churches scholars invoked religious texts to confront epidemics and disasters and their attitudes were representative of the rational trends in islam and christianity in addition they followed a universal humanistic character rejected intolerance and coercion against other religions and societies and viewed humanity as one unity inflected with the pandemic rather than a punishment for a particular sect or people 24 this wise religious trend made people aware of the dangers of the pandemic called for the need to overcome political and ideological differences and promoted the need to stick to the moral values of tolerance justice and hope and to reject extremism violence and racism through complying with the measures forced by the authorities 25 this attitude was enough to spread peace in the hearts of people and acknowledge them of the threats of the pandemic and the necessity of cooperation and solidarity this also contributed to overcoming the pandemic materially and morally in addition this attitude contributed to strengthening the official efforts and helped sustain a secure and quiet environment for doctors and other sectors to control the virus 26 the attitude of the clergy on the pandemic reflects a positive image in dealing with the pandemic as they reinforced the principles of religion that require adherence to the measures of the ministry of health in doing so scholars emphasized the principle of preserving human life as the top priority 27 the matter necessitated the establishment of religious rites at homes away from gatherings and did not lead to their disruption or cancellation the ruling is fixed but the application of the ruling is accommodated within the circumstances and contexts 28 christianity has an active role in urging cooperation and solidarity among christians in overcoming the dangers of this pandemic with the accelerated steps of countries towards more precautions and strict restrictions on religious rituals to prevent the outbreak of covid19 several international churches decided to take parallel measures including closure of or shifting some rituals that are used to be performed in religious gatherings a religious trend emerged in the christian community represented by most churches which bet on introducing the moral dimension in christianity and presenting it as a savior of the abject failure of western governments in managing the crises and risks of the pandemic this trend evoked the christian moral values necessary to handle covid19 representing a regenerative tendency that emerged in christianity recently it is a response to the development and radical reform that occurred in christianity and was known as the liberation of theology christianity in this new era shifted from the preserved theological templates that it placed in a dogmatic fence and shifted to a functional and practical form of christianity that responds to the real challenges facing the christian community therefore the catholic church called through the papal encyclicals to surpass the obsolete approach of the church in confronting epidemics in the past 29 in addition the catholic church recommended modifications in the practice of devotional rites responded to the arising scientific issues and health instructions and urged christians to physically distance themselves from religious gatherings and to find new ways for worship using technology and the internet the concept of the church in the new perspective is not limited to a place of worship rather a church means the people of god the word church means the people who have been summoned and therefore everyone will be called upon to work on finding new ways to cooperate and care for the weak in times of crisis to help the needy and the poor and to provide them with a helping hand the true christian is required to share with other christian brothers in their crises islam also commanded physical distancing from people with infectious diseases this is confirmed in the hadith flee from a leper as you would flee from a lion 30 on the authority of ʿalī bin abī ṭālib the prophet said do not keep looking at the lepers and if you speak to them make a distance of a spear length between you and them 31 it was forbidden to contact lepers because it was a contagious disease that spread among people at that time 32 this attitude towards leprosy can be generalized against all infectious diseases the history of islam is replete with many examples that reflect the role of religion in dealing with disasters epidemics and pandemics chief among them is the way umar ibn alkhaṭṭāb dealt with the plague of emmaus in the levant where he referred to the hadith of the messenger about the plague if you are informed of the plague in a land do not enter it and if it falls on a land while you are in it do not leave it 33 this hadith shows that the first person to institute social isolation and quarantine measures was the prophet as he ordered people not to leave their homes during the outbreak and spread of the epidemic these precarious measures against leprosy apply to all other infectious diseases this is what was confirmed by the egyptian dar aliftaa when declaring if people go out in the time of epidemics in collective marches to pray collectively and supplicate for the removal of the epidemic there would be a higher risk of increasing the spread of the disease thats why this is one of the forbidden abominations and deviations in the religion 34 ibn ḥajar emphasized that by saying as for gathering for it the epidemic as they do for the prayer for rain it is a deviation in religion that occurred in the great plague in damascus during the year seven hundred and fortynine he also mentioned people went out to the desert including most of the great people of the country prayed and sought help but the plague became more infectious after that 35 these extracts indicate the prevention of gatherings during the epidemic even if it is to pray in order to lift the epidemic which is what jurists and religious scholars relied on their method of dealing with the covid19 pandemic showing the importance of following the approach of the predecessors to limit the spread of infection thus christianity and islam prohibited gatherings whether it was for the sake of performing worship jobs or even supplication both religions tried to search for a suitable alternative for that whether it was through attendance with the need to pay attention to physical distancing and taking the necessary measures or even taking advantage of the means of technology to gather for worship and supplication especially in christianity which was keener to implement this islam was keener to stress that one should not leave a country where the epidemic had spread to prevent mixing and transmission of the epidemic in this context some christian moral principles and values in the bible were revisited through deep discussions and dialogue to highlight their true meaning like love and altruism under covid19 generosity was magnified took the lead in virtues and was attributed as an act of saints the church called on christians to help the weak the destitute and those at risk to secure their living and compensate for their health needs in order to confront the psychological crisis that occurred with the covid19 pandemic the church worked to charge its followers with a healing energy of faith derived from the most famous teachings of christ so in everything do to others what you would have them do to you for this sums up the law and the prophets 36 and greater love has no one than this to lay down ones life for ones friends 37 accordingly it can be said that christian moral teachings especially in times of crisis gave christians strong faith energy and courage in providing assistance to the needy to the extent that the life of an individual christian seemed less important than the life another fellow christians 38 one of the greatest strengths of the christian faith is that it teaches christians that god knows the end from the beginning so a believer should not be surprised by what happens as god is always with his people regardless of the dangers they face the central tenet of the christian faith is that god lived with them as human beings who shared with the believers their sorrows and who comforted them to relieve them of their affliction most churches responded to the health measures and precautions applied by states and called on christians to obey rulers and leaders according to the instructions of the bible christians were reminded that strict adherence to these measures is not just a matter of personal protection but for the good of all the church expressed sympathy with medical groups and called on christians to pray around the world for medical workers who put their lives at risk during the pandemic for governments and leaders who must make wise decisions and for scientists as they race against time to develop a vaccine the church directed christians in light of this crisis to the supporting and soothing supplications in psalm 46 god is our refuge and strength an everpresent help in trouble therefore we will not fear though the earth gives way and the mountains fall into the heart of the sea though its waters roar and foam and the mountains quake with their surging there is a river whose streams make glad the city of god the holy place where the most high dwells god is within her she will not fall god will help her at break of day 39 dependence on medical science does not mean ignoring the spiritual aspect a muslim has to resort to praying to god supplication repentance seeking forgiveness and drawing closer to god almighty with every good deed ibn ḥajar says among what everyone should hasten to are responding to grievances paying debts repenting to god regretting for going back to disobedience and writing a fair will without doing injustice this is required at all times and is confirmed when diseases occur in general and for those who become infected in particular 40 this can be achieved through supplication prayer and repentance to god ibn ḥajar says the one who is distressed with a serious calamity should hasten for prayer 41 alaynī says they should hasten to the remembrance of god prayer and charity because that is what god repels affliction with 42 in addition it is important to seek social solidarity and spending in the cause of allah as the prophet says the food of one person suffices for two the food of two persons suffices for four and the food of four persons suffices for eight 43 imam alnawawī says in this hadith the aim is to exhort people to share food as though little it may be it will be sufficient and blessed for those present 44 islam furthermore outlaws monopoly as the prophet says no one hoards but the sinner 45 the guilt of monopoly grows and intensifies if the monopoly occurs in times of epidemics calamity and hardships because this leads to injustice and overburdening and stirs up panic anxiety and fear thus religious scholars have taken a position stemming from the teachings of islam in confronting the pandemic they called for following the precautionary measures imposed by the authority based on the available knowledge of medical resources they assured that medication and the search for medicine is a matter approved by islam and its teachings when calamity descends in ṣaḥīḥ albukhārī the prophet said god does not send down a disease but that he creates a cure for it 46 it was reported in ṣaḥīḥ muslim that the prophet said every disease has a cure if the medicine suits the disease it will be cured by the will of god almighty 47 jurists agreed that treatment with medicine and guarding against the epidemic is obligatory 48 following these teachings the islamic civilization enjoyed an abundance of hospitals medical and pharmacological schools and was exclusively concerned with scientific diagnosis and treatment away from superstitions hospitals in the muslim world treated all people without discrimination between muslims and nonmuslims or between the rich and the poor 49 the terrible plague of the 2 nd century which killed nearly a quarter of the population of the roman empire contributed to the spread of christianity as saints cared for the sick and set an example of devotion and adherence to the morals of christ the most famous epidemic in christian history was the siberian plague in the 3 rd century in which the christian clergy did so well resulting in the tremendous growth of christianity saints devoted themselves to the care of the living and the death rates in cities with christian communities were half that of those in other cities 50 ethical values in christianity and islam have revived in our faith morals and our family and human relations and made us believe that adhering to our morals will guarantee us victory over crises and epidemics through solidarity and cooperation with our brothers regardless of race gender religion or sect it also revived in us a feeling of cooperation a sense of the pain of others and meeting their needs for food and medicine it taught us to reconsider our behaviors and actions in what is known as moral accountability therefore the crisis made us feel that we must return to the moral values that characterize christianity and islam to create a world order based on love tolerance justice and human brotherhood all people are brothers equal in rights and duties as called for by pope francis and the grand imam of alazhar aḥmad alṭayyib who stated we will be fine when we do good to every human being as they deserve51 the pandemic alerted us to the existence of many common moral values between christianity and islam such as tolerance love altruism the necessity of believing in god and destiny feeling the pain of others and the necessity of bearing social responsibility and having good morals this urges us to look for ways to address extremism hatred and violence against the others due to the need to move forward together and to spread love tolerance coexistence and the defense of human rights islamic values clearly showed how and to what extent a persons belief is related to the correctness of his actions and that this is linked to a persons faith and commitment to religion and morals christianity has shown the depth of the link between christian moral values and christian belief a person who adopts his religious values and builds his behavior on them can only be a benevolent person as his religion wanted him to be whether he was a christian or a muslim priests and monks were keen to conduct rituals and liturgies in different ways and were keen to convince people of this carol kutsushi a christian residing in nairobi says we will conduct the rite of the holy communion on good friday through the zoom application on the internet because of the current situation we cannot get the bread that is used in churches so we will use another material that represents bread we will take a piece of plain bread and a quantity of grape juice pray over these materials we have chosen and then recite the communion together the church to which carol belongs usually holds small weekly gatherings in the houses of the followers but she says that these gatherings are now taking place through the internet and as a result the number of times members of these gatherings contact each other has increased she says our religious leaders send us weekly materials for discussion and we discuss them via zoom every tuesday and friday and then we pray it is not without difficulty but i think it is a beautiful way to get closer to the lord while you are sitting in your home especially since the children are participating in reading the bible carroll confirms that this method has many benefits as she says i think it brought us closer to each other than before in britain the islamic tent project usually organizes a collective iftar in which a tent is set up in an open yard in london or other famous sites the followers of various religions are invited to attend and eat breakfast this year they held a virtual iftar by sending boxes that people can build their ideal experiences for breakfast this included recipes games and brochures that show facts about islam and the breakfast feast continued throughout the month through the zoom application 52 a number of muslim scholars and clerics also tried to adhere to preventive measures and they were keen that people pay attention to them by holding prayers and some possible rituals through applications such as zoom or broadcasting holiday masses on television screens eid alfitr and eid aladha prayers were also broadcast in many countries via live broadcasting on facebook several sheikhs and religious scholars in arab countries broadcast tarawih prayers on their facebook pages throughout the month of ramadan in addition to recording religious lectures for those interested at the same time some found internet applications to be not a bad way to facilitate remote marriage matters however it was not possible to hold some particular rites and rituals from a distance such as the baptismal masses or blessing water during the holy week nevertheless one of the priests in michigan found a way to complete the ritual by using a green water toy gun the picture of the water toy gun went viral on social media 53 with these clear proofs in islam and christianity that attest to the true essence of the teachings in the two religions in the face of the emerging pandemic the extremist discourse that refuses to adhere to the preventive measures in churches mosques and places of worship should be rejected combating false religiosity in interpreting the pandemic in christianity and islam during the covid19 pandemic some radical religious trends emerged that took a stance that is completely different to that of the official stance of christianity and islam such extremist stance contributed to the spread of the disease and the transmission of infection several christian religious leaders offered metaphysical explanations for the spread of the virus and the repercussions of its dangers to humanity claiming that it is a divine punishment for the spread of sins and misdeeds anba agathon bishop of maghāgha who is from the hardline in the egyptian church declared coronavirus is the wrath of god and his punishment for humanity for their evils he punishes them with an unprecedented deadly epidemic 54 among some muslims it was rumored that the coronavirus is a divine retribution for the secular communist regime in china because of the injustice aggression and violence they practice against muslims others described the pandemic as the soldiers of god avenging for the oppressed 55 other pseudoreligious persons in christianity and islam claimed that believers are immune from the virus and accordingly refused to close places of worship and called for the continuation of religious rites opposing the precautionary measures 56 some ultraorthodox christian churches sued their governments to get exemptions from stayathome orders others said they would not comply with these orders and would hold their religious services in person at easter this caused tension between these countries and these churches 57 the pew research center reported that more than 20 of white evangelicals more than any other group believe that parents should be able to make the decision not to vaccinate their children even if doing so may cause health risks to other children and adults 58 christian radicals tend to include vaccinations within a worldview that generally distrusts science and views scientists as a threat to the moral order in some cases these protests were led by clergy and church leaders in the conservative evangelical community where they used their pulpits to discourage church members from getting vaccinated 59 the main reason behind this challenge and the failure to respond to all the precautionary measures to limit the spread of the virus is the biblical quotations the radicals use mostly out of context to justify their extremist positions they view their religion as the source of immunity from the virus and they say that gatherings are necessary because true christians welcome death they accuse the state and the authority of being the cause of the outbreak of this pandemic to eliminate the chosen few fayrūs kūrūnā fī irān awāmil tataallaq bi rijāl aldīn march 11 2020 retrieved nov 30 2021 shorturlat believers some evangelists have even linked vaccinations to the symbol of submission to the antichrist 60 misguided interpretation of religious texts has also cast a shadow over some extremist islamic trends that spread rumors and myths about ways to treat the pandemic this is what the global index of the egyptian dar aliftaa warned against emphasizing that 55 of the myths concerning the cause and treatment of the pandemic were published on social media 40 of them were reflecting ignorance of religion or wrong interpretation of the verses of the quran and the prophets tradition and 30 of these myths aimed at spreading panic and anxiety among people to achieve certain goals 61 the most dangerous of these myths are that covid19 was mentioned in surah almuddaththir 62 that whoever finds a hair in surah albaqarah and drinks its water will be treated from the virus 63 that the soil of alḥusayn heals the afflicted 64 and many other myths and lies 65 believing in these superstitions and rumors only reflects ignorance or misguided religious interpretation some people use the texts out of context to support falsehood by interpreting the sacred texts in a way that serves their purposes they claim that the fatwas issued by official religious figures are engineered to suit the rulers whim or to serve the dominion of politics by dedicating money to certain sects and doctrines by doing so the sacred texts turn from a solution to the crises into fuel in the crisis industry god states in the quran layer upon layer of darkness when he the misguided holdeth out his hand he scarce can see it and he for whom allah hath not appointed light for him there is no light q 24 40 these dissonant voices of extremist groups in the two religions and their misinterpretation of the pandemic should not obscure the fact of the efforts of the leaders of the two traditions and their valiant sacrifices in resisting the pandemic in conclusion the researchers confirm that the covid19 pandemic caused enormous tensions in international relations revealed to the world the flaws and shortcomings of many major superpowers uncovered the failures of materialism and its futility in managing the global health crisis and turned the health crisis into a global moral crisis the adversities and calamities have revealed the essence of matters the true nature of peoples and nations and uncovered the vanity layer of civilization that developed countries tore and regressed to robbery and piracy the study showed the urgent need for a new religious discourse that goes beyond the dialectical metaphysical approach into a more ethical religious approach through which these values are employed to serve man and society in the face of the dangers of disease and its negative repercussions the study emphasized the rich moral heritage that is stored in the two religions christianity and islam which constituted a safe haven of protection for their followers from the dangers of the emerging pandemic especially with the terrible international failure and the inability of governments and international institutions to face this challenge the study also marked the positive attitude of religious scholars and leaders in addressing the pandemic through the acknowledgment of the principles of religion that require the necessity of commitment and taking health precautions following the principle of preserving the human soul undoubtedly islamic and christian morality acted as an important factor in the context of the crisis and tried to explain and exercise a degree of societal control over societies in the face of the epidemic and related issues and problems the positive role of islamic and christian morality in the pandemic period is related to the nature of the problems faced by societies during the spread of the virus as societies were overwhelmed by a state of tension and anxiety to the point that some despaired of the human ability to treat the disease here the role of islamic and christian morals appeared in achieving and restoring stability psychological rest and reassurance for members of the society ethics play a major role in a productive and peaceful life as they help individuals to accept inexplicable facts with ease in addition islamic and christian moralities have worked to refine the individual tendencies that have accompanied the state of tension and anxiety that resulted from the outbreak of the epidemic islamic and christian moralities resist the natural tendency of humans to exaggerate individual selfishness materialism and narrow rationality they encourage individuals to show solidarity altruism and help others there is another aspect that we can see in islamic and christian ethics which is the aspect related to the obligatory function of individuals which requires putting forward a set of instructions and laws that aim to organize the lives of individuals and societies where they control their behavior especially in times of crisis this pattern appears in islamic ethics through religious texts that control relations among individuals during times of hardship this comes in accordance with the prophets hadith about the plague when directing individuals not to enter or leave the places where the epidemic spreads which religiously establishes the concept of quarantine to confront epidemics likewise christianity morals advocated the same through the sermons of many priests christianity as well as islam had a role in confirming that the crisis and the pandemic were a destiny from god and not a punishment as some radical parties wanted to interpret according to their whims and agenda this appeared in the speeches of various religious leaders in sheikh aḥmad alṭayyibs tv message on march 29 2020 he called on individuals and societies to resort to god through prayer and supplication so that god would relieve this crisis and reveal this anguish and concluded his speech by praying he also emphasized the qualities of mercy benevolence and divine relief this aspect of faith was also manifested in the vatican pope franciss prayer on march 27 2020 in which he said we call upon you lord from a raging sea turn to us o lord and do not leave us in the midst of the storm and tell us again do not be afraid that we will cast all our worries on you because you take care of us islamic and christian ethics also played a major role in supporting health policies most religious trends ordered the policies imposed by governments to be followed when religious institutions took decisions demanding the cessation of collective religious rites and gatherings and demanded individuals to adhere to the precautionary measures religious institutions and most of the sheiks and clergymen demanded people adhere to these measures and consider this as one of the things that serve the fundamental goals of religions which presented the idea of preserving self over other things the religious muslim leaders used the historical experience and religious texts that allow the closure of places of worship and the suspension of religious rituals such as collective prayers and pilgrimage religious institutions in many islamic countries issued fatwas on the necessity of stopping collective religious rituals to prevent the harm resulting from the outbreak of the virus and the same was the case with christian religious institutions as churches banned gatherings collective prayers and celebrations in addition islamic and christian ethics presented a framework supported by religious texts and principles to manage societies during the pandemic that focused on a number of values such as compassion community solidarity altruism helping others and cooperation as a result islamic religious institutions issued many fatwas that allow the early payment of zakat to meet the needs of the poor and the needy in light of the circumstances resulting from the pandemic the grand imam of alazhar also decided to double the value of the monthly subsidy disbursed by the egyptian house of zakat and charities to its beneficiaries during the months of april and may 2020 the religious organizations and institutions in western countries continued their social solidarity activities and called on individuals to donate and contribute to efforts to combat the virus the study shed light on the proper employment of religious texts to combat the pandemic and to benefit from the luminous historical experiences in christian and islamic histories in the face of the dangers of epidemics it furthermore denounced and condemned the religious misinterpretations of the pandemic as they do not represent the essence of the two traditions

religious beliefs have always been the stimulating motives for human behavior mans need for religion is not specified to a certain era in time rather it extends over all the times and eras as a man still invokes religion in the face of everrising challenges one of the most serious of these challenges that humans constantly face is epidemics and diseases there is no doubt that the two religions christianity and islam enjoy a high moral heritage this study aimed to demonstrate the impact of the covid19 pandemic on societies and the importance of islamic and christian values in dealing with the pandemic in different societies of the world by reviewing and analyzing the discourse of religious scholars and priests and through the sacred texts of the two religions in addition to reviewing the studies that discussed the pandemic and religious values the study explained how the islamic and christian religious discourses employed morals to confront the pandemic as they supported and emphasized the precautionary measures such as home quarantine and social distancing they also stressed the need for unity cooperation and solidarity to confront the pandemic in order to preserve the security of societies